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RC667  .Sa82  1905  Diseases  of  the  hear 


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St0?aa^a  of  tl|^  l|^art 
nnh  Anrta 

BY 

THOMAS  E.  SATTERTHWAITE.  M.  D. 

PROFESSOR    OF    MEDICINE    IN    THE    NEW    YORK    POST-GRADUATE    MEDICAL 

school;    consulting   physician   to   the    POST-GRADUATE, 

ORTHOPEDIC   AND  BABIES'    HOSPITALS;    PRESIDENT 

OF    THE     MEDICAL    ASSOCIATION     OF    THE 

GREATER  CITY  OF  NEW   YORK 


'Progre  *is  the  Law  of  Life*' — BROWNING 


E.    R.    PELTON,    19   EAST    16th    STREET.  NEW  YORK  CITY 


Copyrighted  1Q05 

BY 

'I'hcimas  v.   Satterthvvaite,  iM.D 
New   York 


CONTENTS. 


CHAPTER  I.  PAca 

Diagnosis    of   Heart    Diseases ^ 

CHAPTER    H. 

Endocardiopathies    27 

CHAPTER    HI. 
Acute  Endocarditis    43 

CHAPTER    IV. 
Mitral  Insufficiency 50 

CHAPTER    V. 
Mitral  Obstruction ce 

CHAPTER    VI. 
Aortic  Diseases  67 

CHAPTER   VII. 
Pulmonary  Valve  Affections  82 

CHAPTER  VIII. 
Tricuspid  Diseases  ........,......,..'...,. gj 

CHAPTER    IX. 
Myocardial  Affections ro2 

CHAPTER    X. 
The  Fat  Heart 112 

CHAPTER    XI. 
Fatty  Degeneration  of  the  Heart 124 

CHAPTER   XII. 
Syphilis  of  the  Heart 136 

CHAPTER  XIII. 
Displacements  of  the  Heart ,     142 

CHAPTER  XIV. 
Pericardial  Diseases 159 


Contents 

CHAPTER   XV.  PAGE 

Functional  Cardiac  Diseases  170 

CHAPTER  XVI. 
Pulsus  Infrequens  181 

CHAPTER  XVII. 
Graves'  Disease  194 

CHAPTER    XVIII. 
Angina  Pectoris  207 

CHAPTER    XIX. 
General  Treatment  of  Heart  Diseases 220 

CHAPTER   XX. 

Nauheim  Methods  with  American  Adaptations  230 

CHAPTER   XXI. 
Prognosis  in  Heart  Diseases 243 

CHAPTER   XXn. 

True  Aneurisms  of  the  Larger  Vessels  251 

CHAPTER    XXIII. 
Aortitis    263 

CHAPTER    XXIV. 
Arteriosclerosis    273 

CHAPTER    XXV. 

Surgery  of  the  Heart 285 

APPENDIX. 

I.  Congenital  Heart  Affections   287 

II.  Tumors  of  the  Heart 288 

in.  Aneurism  of  the  Heart  288 

IV.  Parasites  of  the  Heart  289 

V.  Treatment  of  Chronic  Heart  Diseases  at  Franzensbad 289 

VI.  Regimen  in  Chronic  Heart  Diseases 29? 

VII.  The  Modified  Riva  Rocci  Sphygmanometer 293 


PREFACE. 

The  author  of  this  volume  has  tried  to  place  before  the  gen- 
eral practitioner  a  brief,  simple,  but  practical,  presentment  of 
cardiac  and  aortic  affections,  chiefly  from  the  standpoint  of  his 
personal  experience. 

Unusual  opportunities  for  seeing  the  clinical  and  pathologi- 
cal aspects  of  these  diseases  have  furnished  him  with  the  material 
illustrating  the  relation  of  clinical  signs  to  post  mortem  appear- 
ances. Over  a  hundred  cases  from  his  individual  records  are 
given  at  some  length. 

But  the  book  is  not  an  encyclopaedia.  Little  space  is  given 
to  the  Anatomy  or  Surgery  of  the  Heart  or  Aorta,  to  Congenital 
Anomalies  or  Tumors,  or  to  Parasites  of  the  Heart.  And  there 
are  obvious  omissions  of  subjects  that  are  sometimes  treated  at 
length  in  books  on  Heart  Disease.  For  example,  only  brief  men- 
tion is  made  of  the  Sphygmograph,  because  it  is  thought  to  mis- 
lead rather  than  help  at  the  bed-side  or  in  the  consulting  room. 
The  practical  value  of  the  Sphygmanometer,  however,  is  recog- 
nized. Nor  do  theories  or  metl^ojds  of  treatment  that  have  little, 
or  merely  a  historical  value,  receive;  much  notice.  At  the  same 
time  it  is  believed  that  the  exceptional  quantity  and  character 
of  the  data  made  use  of,  will  give  proper  emphasis  to  the  newer 
views  expressed.  From  this  point  of  view,  the  comparative  values 
of  diagnostic  signs,  and  the  relative  frequency  and  gravity  of  valvu- 
lar diseases  are  subjects  that  may  enlist  special  interest.  A  good 
deal  of  space  is  given  to  modern  methods  of  treatment. 

The  volume  is  based  on  a  series  of  articles  that  originally  ap- 
peared in  our  Medical  periodicals,  but  have  been  revised,  while  new 
chapters  have  been  written.     The  majority  of  the  cuts  are  original. 

With  all  its  failings,  for  which  the  author  must  be  responsi- 
ble, it  is  hoped  that  the  general  practitioner  will  find  it  a  useful 
addition  to  his  store  of  handy-books,  helping  him  to  manage  his 
heart  cases  more  intelligently,  and  therefore  with  more  satisfac- 
tion to  himself  and  his  patients. 

March,  1905. 

"That  writer  does  the  most,  who  gives  his  readers  the  most  knowledge, 
and  takes  from  them  the  least  time." — Colton. 


Dedicated 

TO 

I.  B.  S. 


Chapter  I. 
THE  DIAGNOSIS  OF  HEART  DISEASES. 

Success  in  the  diagnosis  of  heart  diseases  calls  for  method, 
thoroughness  and  a  proper  consideration  of  objective  and  sub- 
jective symptoms.  But  method  is  of  the  first  importance,  and  in 
fact  is  absolutely  essential.  Both  positive  and  negative  condi- 
tions should  be  recorded  in  a  systematic  manner.  For  this  pur- 
pose a  blank  such  as  is  given  on  page  8  should  be  used.  It 
is  comprehensive  enough  for  ordinary  clinical  use,  and  if  filled,  will 
tell  its  own  story.  Then  it  should  be  put  aside  for  subsequent  ref- 
erence. 

After  noting  the  date  and  the  patient's  name  and  age  it  may  be 
necessary  to  determine  the  height,  iveight  and  even  the  measure- 
ments of  the  body  or  limbs.  Such  data  are  very  important,  as  for 
example,  in  the  management  of  the  fat  heart,  which  is  closely 
related  to  general  obesity,  where  scales  and  measurements 
are  essential  aids  in  diagnosis  and  treatment.  But  measure- 
ments are  hardly  less  useful  when  wasting  diseases,  such  as  tuber- 
calosis  and  carcinoma,  complicate  the  cardiac  trouble.  The  meas- 
urement chart  on  page  9  is  adapted  for  these  cases. 

First  in  order  among  physical  signs  is  the  pulse.  It  may  be 
frequent  or  infrequent,  according  to  the  number  of  pulsations 
per  minute,  the  normal  being  placed  at  y2,  or  from  70  to  75  for 
an  adult  male.  However,  quick  and  frequent  are  not  synony- 
mous, for  the  word  quick  means  merely  that  each  expansion  of 
the  vessel  is  brief,  in  point  of  time.  The  word  large,  applied  to  the 
pulse,  implies  that  the  vessel  is  well  distended  during  cardiac 
systole.  On  the  other  hand,  in  the  small  pulse,  the  systolic  dis- 
tention is  less  than  normal.  The  pulse  usually  gives  important 
indications  in  heart  disease.  Oppolzer,  it  is  said,  would  make  a 
diagnosis  of  aortic  insufficiency  before  his  hospital  class,  after 
merely  placing  a  hand  on  the  posterior  tibial.  For  he  held  that 
the  trip-hammer  rhythm  is  pathognomonic.^.  In  arterio-sclero- 
sis  a  diagnosis  may  be  made  from  the  resistance  felt  in  the  walls 


^  It  probably  is,  excepting  in  aneurism  and  anaemia. 


Diagnosis  of  Heart  Diseases 
Examination  Blank. 


Name 

Date 

Age 

Weight 

Pulse 

Resp. 

Height 

Temp. 

Palpitation 

Head  Symptoms 

Pain  Apex 

Prscordium 

Liver 

Elsewhere 

Other  Sul)jective  Symptoms 

Phys.  Appearance 
Impulse 

Bloodvessels 
Thrill 

Aortic  Direct 
Aortic  Regurg. 
Mitral  Direct 
Mitral  Regurg. 

Pulmonary  Direct 
Pulmonary   Regurg. 
Tricuspid   Direct 
Tricuspid  Regurg. 

T.,     ,        f  Pulse 
Rhythm  •<  ^      ,. 

(Cardiac 

Liver 

Spleen 

Lungs 

Digestion 

Urine 


Notes 


Treatment 


Medicines 
Exercises 
Diet 
L    Baths 


Diagnosis  of  Heart  Diseases 

Measurement  Chart. 


CALF 


ANKLE 


Fig.  I. 


WRIST 


Name 

...Age... 

Height.... 

p 

1 

u 

4_, 

+J 

j= 

QJ 

j= 

<u 

i= 

<u 

a       -S? 

<+- 

2       ii 

U 

U 

O 

^ 

^ 

ffi 

u 

< 

Q 

^ 

10  Diagnosis  of  Heart  Diseases 

of  the  artery.  Imleed,  next  to  auscultation,  the  pulse  is  our  most 
reliable  aid  in  diagnosis.  For  freciuency,  rhythm,  rapidity  and 
tension  have  each  of  them  definite  meanings. 

The  frequent  pulse  occurs  after  brisk  exercise,  in  fevers,  alco- 
holism, hysterical  conditions,  phthisis  and  many  other  disor- 
ders. In  heart  diseases  it  also  occurs  during  loss  of  compensa- 
tion :  in  the  coffee  and  tobacco  heart,  and  in  cardiac  neuroses ; 
but  it  may  be  a  coincidence  rather  than  a  symptom  in  heart  dis 
ease.  It  is  paroxysmal  or  chronic.  It  is  also  common  in  loco- 
motor ataxia.  One  of  my  patients  suffering  from  tubercular 
phthisis  with  locomotor  ataxia  had  for  several  years  a  pulse  averag- 
ing between  120  and  130,  and  yet  led  a  tolerably  active  busi- 
ness life.  The  greatest  rapidity  is  seen  in  the  paroxysmally  fre- 
quent pulse,  as  in  Graves  disease.  In  the  latter  I  have  seen  it 
reach  200  and  upwards.  In  fact,  in  one  of  these  cases,  I  could 
not  count  it,  and  I  presume  nothing  short  of  the  sphygmograph 
could  have  measured  its  frequency.  There  is  also  an  hereditary 
element  in  the  frequent  pulse. 

On  the  other  hand  the  infrequent  pulse  is  often  seen  in  cen- 
tral or  peripheral  nervous  disturbances,  toxaemias  and  wasting- 
affections  ;  sometimes  in  persons  w^ith  deficient  vitality.  It  is> 
not  very  uncommon  to  have  a  pulse  of  60  or  even  less,  in  chronic 
degenerative  cardiac  changes.  Occasionally  during  a  prolonged 
attack  of  heart  failure,  a  pulse  may  remain  continuously  in  the 
30's  for  weeks  at  a  time.  I  had  such  a  case  in  1900.  Recovery 
ensued,  at  least  so  far  as  that  the  patient  was  able  to  go  about 
and  enjoy  life  much  as  before  the  attack.  Then  there  is  the 
pliysiologically  infrequent  pulse.  Napoleon  is  said  to  have  had' 
a  pulse  of  40.  I  saw  a  patient  in  1901  w^ho  had  just  suffered  from 
an  a]^oplectilorni  attack.  His  pulse,  also,  was  40.  Two  years 
later  when  I  examined  him  it  was  from  36 — 40.  He  was  in  fairly 
good  condition.  There  has  been  no  change  since  then,  so  far  as  I 
know.  A  patient  I  saw  in  1903  with  Dr.  Swasey  of  New  Britain,. 
Connecticut,  has  had  a  pulse  of  about  28  for  the  past  year  (1904). 
and  at  last  accounts  was  attending  to  an  active  business,  and  had 
recently  returned  from  a  trip  to  Europe^  ■ 

In  these  cases  it  is  important,  however,  to  distinguish  between 
the  infrequent  pulse  due  to  infrequent  cardiac  action,  or  mere 
failure  of  the  blood  waves  to  reach  the  wrist.  In  a  lady  recently  un- 
der my  care,  where  the  heart  contractions  averaged  80,  only  30  pulse 
beats  were  felt  at  the  wrist,  when  she  first  came  under  my  observa- 


Diagnosis  of  Heart  Diseases  II 

tidn.  She  had  been  under  a  severe  nervous  strain,  but  made  a 
successful  recovery. 

Some  of  the  more  important  varieties  of  pulse  are  worthy  of 
mention. 

The  allernating  pulse  is  indicated  by  a  fulness  or  diminution 
of  every  alternate  beat.  In  the  intermittent  pulse  some  of  the 
heart  weaves  fail  to  reach  the  wrist,  as  was  the  character  of  the  pulse 
in  the  case  just  given.  In  the  deficient  pulse  the  "missed  heats"  are 
diie  to  failure  of  the  heart  to  contract.  In  the  bigeminal  and  tri- 
geminal pulse  the  second  and  third  beat  respectively  fails  to  reach 
the  wrist. 

The  arhythmic  pulse  is  one  of  the  signs  of  heart  failure. 
When  there  are  three  even  or  similar  heart  beats,  the  pulse  is 
said  to  have  the  triple  or  gallop  rhythm,  similar  to  the  rat-tat- 
tat  of  a  galloping  horse.  Sometimes  as  in  delirium  cordis,  which 
is  apt  to  occur  in  profound  heart  failure,  the  pulse  is  wholly 
irregular  in  force  and  frequency,  and  as  regards  the  intervals  be- 
tween beats ;  and  yet  as  we  all  know,  recovery  is  possible.  This 
matter  will  be  further  considered  in  connection  with  heart  sounds. 
It  is  always  well  to  note  the  rate  of  respiration  in  heart  diseases, 
because  it  is  often  hurried  or  embarrassed.  In  the  Cheyne-Sfokes 
variety  the  patient  stops  breathing.  Then  shallow  respirations 
begin  slowly,  increasing  in  depth  and  rapidity,  until  they  reach  a 
certain  point,  after  which  they  decline,  getting  slower  and  more 
superficial  until  they  finally  stop.  This  cycle  is  then  repeated  and 
occupies  from  a  half  a  minute  to  two  minutes.  In  acute  heart 
diseases  and  in  complications,  the  temperature  also  gives  import- 
ant information.  As  palpitation  is  one  of  the  cardinal  symptoms 
of  heart  disease  no  examination  is  complete  without  a  record  of  its 
existence  or  non-exiStence.  Head  symptoms  should  also  be 
noted.  They  are  apt  to  be  marked  in  aortic  disease.  Pain 
should  also  not  be  overlooked.  Pain  at  the  apex  is  common  in 
endocarditis.  The  subjective  pain  of  angina  in  the  precordial 
region  in  distinctive.  Praecordial  pain  on  pressure  may  be  due  to 
pericarditis.  Pain  over  the  ensiform  is  also  one  of  the  signs  of 
pericarditis.  Pain  over  the  liver  is  common  in  loss  of  compensa- 
tion, owing  to  the  congestion  of  the  organ.  Pain  in  the  left  arm 
arid'  shoulder  is  also  common  in  heart  disease  and  arterio- 
sclerosis. It  is  important  to  determine  whether  there  is  an  im- 
pulse. This  is  apt  to  be  wanting  in  myocardial  affections.  Fail- 
ure of  the  impulse  is  a  warning  that  heart  failure  may  suddenly 


12  Diagnosis  of  Heart  Diseases 

supervene.     A  ilirill  indicates  obstruction  at  a  valve  or  in  a  vessel. 
It  is  one  of  the  most  important  signs  in  mitral  stenosis. 

In  listening  to  the  heart,  one  should  make  note  of  what  is 
heard  at  each  valve,  both  during  systole  and  diastole.  The  fail- 
ure to  discover  the  more  uncommon  heart  lesions,  has  been 
largely  due  to  neglect  of  this  precaution.  According  to  the  pres- 
ent scheme,  the  character  of  the  direct  and  indirect  sounds  at  each 
of  the  four  valves  should  be  recorded. 

In  cases  of  irregular  pulse  the  cardiac  rhythm  should  be  noted 
as  distinguished  from  the  pulse-rhythm. 

In  chronic  affections,  the  liver,  spleen  and  liDigs  are  pretty  sure 
to  be  engorged  with  blood  at  some  time  or  other,  and  the  en- 
gorgement may  become  permanent.  In  the  lungs,  chronic  inter- 
stitial thickening  and  embolic  deposits  are  also  to  be  found,  with 
bronchorrhea,  if  not  chronic  bronchitis.  The  digestion,  too,  should 
be  considered.      It  is  apt  to  be  disordered  in  chronic  heart  diseases. 

The  last  few  years  have  seen  important  modifications  in  our 
views  of  the  normal  position  and  shape  of  the  heart.  Before  the 
X-ray  was  used  in  clinical  medicine,  the  teachings  of  Luschka 
and  Spalteholtz  ( 1900)  were  successively  accepted  as  guides  for 
students  of  topographical  anatomy,  because  their  drawings  from 
frozen  sections  w^ere  thought  to  represent  living  conditions.  Now, 
however,  it  is  realized  that  these  represent  only  the  relations  of 
the  organ  to  its  environment,  as  seen  in  death. 

Besides  better  mehods  of  manual  percussion,  with  skiagraphy, 
fluoroscopy'  or  fluorography  have  so  combined  to  confirm  the  inac- 
curacies of  the  anatomists  that  corrected  diagrams  of  the 
heart  wath  its  relations  to  the  other  thoracic  and  abdominal  or- 
gans have  become  necessary  (Figs.  3  and  4).  This  fact  has 
been  recognized  in  some  of  the  more  recent  text-books. 

Until  a  comparatively  recent  date,  various  plans  w^ere  in  use 
for  mapping  out  the  heart.  Some  examiners  were  able  to  out- 
line it  fairly  well  by  percussion,  while  others  relied  on  dul- 
ness  and  flatness.  Believers  in  the  latter  plan  make  the 
areas  of  cardiac  dulness  and  flatness  fall  within  two  tri- 
angles, the  larger  including  the  smaller ;  the  larger  triangle  hav- 
ing for  its  vertical  side  a  line  let  fall  perpendicularly  from  the 
episternal  notch  ;  for  its  base,  a  horizontal  line  drawn  to  meet  it 
from  the  upper  border  of  the  sixth  left  costal   cartilage   at  its 


■  First  brought  to  the  attention  of  the  profession  by  Dr.  H.  Campbell 
Thompson,  of  the  Middlesex  Hospital,  in  The  Lancet,  of  Oct.  10,  1896,  and 
Dec.  12,  1896. 


Diagnosis  of  Heart  Diseases  13 

junction  with  the  rib.  The  hypothcnuse  connecting  their  extrem- 
ities is  drawn  from  the  vertical  line  at  the  level  of  the  upper 
border  of  the  second  left  costal  cartilage  to  the  point  usually  oc- 
cupied by  the  heart's  apex.  The  lesser  triangle  is  formed  of  the 
same  vertical  and  same  base  line ;  but  the  hypothenuse,  leaving  the 
vertical  line  at  the  level  of  the  third  left  costal  cartilage,  passes 
downward,  paralleling  the  other  hypothenuse.  The  areas  of  dul- 
ness  and  flatness  are  presumed  to  be  found  within  the  larger  tri- 
angle, flatness  within  the  smaller.  This  conception  is  manifestly 
erroneous.  Besides,  flatness  is  no  proper  guide  for  the  dimensions 
of  the  heart.  The  flat  areas  change  with  every  breath,  as  the  to- 
and-fro  movements  of  the  lungs  alternately  diminish  and  en- 
large them.  Further,  the  heart  neither  corresponds  to  angles,  nor 
has  them  during  life.  Another  class  of  practitioners  does  not  at- 
tempt to  delimit  the  heart,  but  simply  indicates  by  vertical  lines 
the  extreme  right  border  and  extreme  left  border  and  the  apex.  In 
women  and  in  stout  people  there  is,  of  course,  manifest  difficulty 
in  all  these  matters,  and  yet  fluorography  shows  that  in  a  male  of 
ordinary  build,  the  heart  can  be  mapped  out  in  its  entire  contour 
up  to  the  origin  of  the  great  vessels  with  sufficient  accuracy  for 
practical  purposes.  For,  by  the  X-ray,  the  whole  inferior  border 
of  the  heart  is  brought  plainly  into  view ;  indeed,  as  the  diaphragm 
descends  it  leaves  a  vacuum  between  itself  and  the  heart.  This 
line  cannot  be  delimited,  however,  by  any  kind  of  percussion. 
But  inasmuch  as  X-ray  work  is  not  often  available  in  the  office 
or  at  the  bedside,  it  is  well  to  know  that  in  ordinary  practice  enough 
of  the  cardiac  borders  can  be  determined  by  percussion  for  practical 
purposes,  and  in  the  following  way: 

With  a  dermatographic  penciP  draw  on  the  skin  a  horizontal 
line  from  nipple  to  nipple,  defining  each  by  a  circle  (Fig.  2)  ; 
next  draw  a  vertical  line  from  the  episternal  notch  to  the 
point  of  the  ensiform  appendix.  Then  trace  by  percussion  the 
right  and  left  borders  of  the  heart.  This  can  be  done  nearly  to 
the  inter-mammillary  line.  Designate  the  apex  by  an  X.  Con- 
nect the  two  lines  at  the  apex  by  continuing  the  curved  lines  on 
the  same  arcs  of  circle,  as  have  been  already  drawn  above  the  hor- 
izontal line,  and  the  contour  of  the  heart  will  be  indicated  with 
sufficient  accuracy.  Except  in  stout  people,  or  women  with 
flabby  breasts,  the  nipples  are  reliable  landmarks. 


^  Faber's  is  not  so  good  as  the  Express  zvax  crayon  used  in  marking 
express  packages. 

A  tracing  made  with  these  crayon  on  a  sheet  of  French  vegetable  fibre 
paper  laid  on  the  skin  may  be  kept  for  subsequent  reference. 


14  Diagnosis  of  Heart  Diseases 

By  these  two  simple  lines  the  relation  of  the  heart  is  shown 
to  the  middle  line  of  the  body,  and  the  dilatation  of  the  several 
chambers  of  the  heart  brought  into  contrast.  Fig.  2  is  the  car- 
diogram of  a  patient  who  was  under  my  care  in  1891.  It  shows 
clearly  the  contractions  that  took  place  between  ]\larch  1st  and 
April  1 2th  and  how  a  record  of  thcni  was  kept.  Of  course,  this 
was  an  unusual  case,  the  patient  being  a  neurotic  subject,  with 
mitral  regurgitation  and  sub-acute  dilatation  of  the  heart. 

With  the  aid  of  these  recent  discoveries,  the  position  and  con- 
tour of  the  heart  may  be  outlined  as  follows:  The  heart's  dulness 
commences  in  the  second  right  intercostal  space,  at  the  edge  of 
the  sternum,  just  abo\'e  the  3d  rib.  Curving  outward  to  the  right 
it  follows  the  line  of  a  segment  of  a  circle  from  this  point  to  the 
apex.  The  line  crosses  the  cartilages  of  the  3d.  4th  and  5th  ribs, 
reaching  the  sternum  at  the  fifth  right  costo-sternal  junction  ;  l)Ut  the 
line  is  never  more  distant  from  the  sternum  than  the  breadth  of  a 
rib,  and  the  most  distant  point  is  on  the  4th  rib.     (Fig.  3). 

On  the  left  side  the  line  of  dulness  commences  in  the  second 
interspace,  just  below  the  2d  costal  cartilage,  and,  curving  to  the 
left  so  as  to  form  a  segment  of  a  circle,  joins  the  curve  of  the 
right  side,  at  the  apex,  in  the  5th  space.  This  curved  line  crosses  the 
third  costal  cartilage  at  about  the  breadth  of  two  ribs  inside  the 
chondro-costal  junction,  and  the  4th  rib  a  little  more  than  the 
breadth  of  a  rib  from  the  margin  of  the  nipple,  crossing  the  carti- 
lage of  the  5th  rib  about  two  ribs'  breadth  inside  its  costal  articu- 
lation. The  apex  should  be  the  breadth  of  i^  to  2  ribs  inside  the 
inner  line  of  the  nipple. 

The  heart  in  life  is  ovoid  in  shape,  its  right  and  left  borders 
comprising  regular  arcs  of  circles  which  meet  at  the  apex,  form- 
ing, of  course,  not  an  acute  angle,  but  a  rounded  point. 

In  determining  the  contour  and  position  of  the  heart,  feel  for 
the  apex  beat.  In  a  doubtful  case  (as  in  myocardial  disease)  iden- 
tify the  point  at  which  the  heart  sounds  are  best  heard  by  the 
stethoscope.  If  the  sounds  are  still  obscure  let  the  patient  walk 
briskly  around  the  room,  a  few  times,  so  that  the  organ  will 
act  with  more  energy.  In  spare  people  there  should  be  little 
difficulty  in  mapping  out  the  outline  of  the  heart  on  the  right 
side  by  percussion,  at  least  from  the  2d  right  interspace  as  far 
as  the  4th  right  interspace,  or  possibly  the  5th  right  costal  carti- 
lage, and  certainly  to  the  inter-mammillary  line  (see  Fig.  3). 


Diagnosis  of  Heart  Diseases 


15 


However,     it     is     not     essential     to     map     out     the     entire 
contour  by  percussion,  for  j:;^ivcn  the  apex  and  the  arc  of  a  circle 


r;^^^^^^^      X^ 

\          A  /r\ 

^^  ^     1  i 

■■  ■                    ■■'.-..■          ,■'■.,  ■■;■             ■  :,         :!??,  .    .  ■ 

:;:--.„.^^--J- Vill2 

'"""^--,.,..._  _...^i' March  1 

Fig.  2. 
Cardiogram. 


Fig.  3- 
Relation  of  the  heart  to  the  viscera. 


1 6  Diagnosis  of  Heart  Diseases 

between  the  2d  right  interspace  and  5th  rib,  the  remainder  of  the 
arc  can  be  estabHshed  by  simply  extending  its  known  portion  to  the 
apex.     (Fig.  2.) 

Percussion  can  not  delimit  the  contour  between  the  5th  right 
sterno-costal  junction  and  the  apex,  because  of  the  interposition 
of  the  liver  and  stomach.  However,  this  is  not  very  ma- 
terial, for  the  reasons  just  given.  On  the  left  side  it 
is  easier  to  define  the  heart's  margin,  because  the  greater  resonance 
of  the  lungs  makes  the  percussion  note  (owing  to  its  greater  dis- 
tance from  the  sternum)  contrast  more  sharply  on  the  left  than 
on  the  right  side.  Usually  we  can  delimit  the  heart  as  far  as  the 
4th  rib,  sometimes  as  far  as  the  inter-mammillary  line  (Fig. 
3),  occasionally  a  trifle  lower.  But  on  either  side  we  have 
determined  the  line  of  curve,  and  we  have  but  to  continue  both 
and  they  will  intersect  at  the  apex.  It  is  true,  as  Gerhardt  says, 
(Lchrb.  d.  Aiisc.  and  Perc.  Tuebingcn,  1890)  that  the  heart  is 
capable  of  displacement  to  one  side  or  the  other  from  1^4  to  2^ 
inches ;  but  this  displacement  is  exceptional,  or  due  to  changes  in 
posture.  In  the  case  of  one  of  my  patients  (Case  XLVIII)  with 
spinal  curvature,  the  apex  was  displaced  beyond  the  nipple  by  the 
curvature,  and  subsequently  brought  2^  inches  inwards,  by  correct- 
ive treatment.  Emphysema  crowds  the  heart  downwards  ;  tumors  and 
effusions  displace  it  laterally;  dilated  abdominal  viscera  push  it 
upwards.  Sometimes,  though  rarely,  when  there  is  a  general  de- 
scent of  the  viscera  as  in  Glenard's  disease,  the  heart  falls.  But 
notwithstanding  these  facts,  the  heart  has  a  standard  position  in 
the  chest,  and  in  healthy  average  patients  the  contour  is  such  as 
has  been  described.  Certainly  the  heart  is  so  fixed  that  it  does 
not  ascend  or  descend  with  the  diaphragm,  as  Gerhardt  has  claimed. 

Owing  to  the  fact  that  the  four  valves  are  so  close  to  one  another 
that  the  extremity  of  a  Bowles'  stethoscope  can  be  made  to  cover 
all  of  them,  more  or  less,  at  one  time,  the  ear  cannot  dis- 
tinguish between  the  various  sounds  distinctly,  if  placed  imme- 
diately over  any  one  of  them.  But  as  the  sounds  are  convey^xl  by 
the  blood  current,  they  can  be  heard  and  differentiated  with  con- 
siderable accuracy,  if  we  listen  somewhere  along  the  course  of 
the  several  currents.  The  location  of  the  valves  is  shoAvn  in 
Fig.  3- 

As  seen  from  the  front,  the  mitral  valve  is  behind  the  3d  left 
interspace,  the  breadth  of  a  rib  from  the  edge  of  the  sternum.  The 
aortic  valve  lies  behind  the  left  margin  of  the  sternum,  adjoining 


Diagnosis  of  Heart  Diseases 


17 


the  3d  interspace.    Tlic  pulmonary  lies  between  the  two,  on  about 
the  level  of  the  aorta. 

The  tricuspid  lies  behind  the  sternum,  a  little  to  the  left  of  the 
median  line,  and  opposite  the  junction  of  the  4th  left  costal  carti- 
lage with  the  sternum.  All  of  the  valves  are  somewhat  to  the 
left  of  the  median  line.  These  statements  as  to  the  shape  and  posi- 
tion of  the  heart  and  the  location  of  the  valves,  vary  from  some 
that  have  been  given ;  but  they  are  the  results  of  careful  personal 
study. 


Fig.  4. 
The  heart  as  seen  from  behind. 

In  this  connection  the  following  note  from  Holden's  Anatomy* 
is  apropos.  It  says,  "Anatomists  dififer  much  in  the  descriptions 
they  give  of  the  relations  of  the  valves  to  the  thoracic  walls,  ii» 
fact,  no  two  agree  in  all  the  details."  And  yet  it  is  proper  to  say 
here,  that  my  statements  agree  pretty  closely  with  those  giveit 
in  Holden,  which  are  that  the  left  auriculo-ventricular  valve  is 
opposite  the  3d  left  intercostal  space  and  about  one  inch  to  the  left  of 
the  sternum.  The  pulmonary  valve  lies  immediately  behind  the 
junction  of  the  3d  left  costal  cartilage  with  the  sternum ;  the 
aortic  valve  is  on  a  level  with  the  upper  border  of  the  3d  left  inter- 
costal space,  just  at  the  left  of  the  middle  line  of  the  sternumu 
The  position  of  the  aortic  and  pulmonary  valves  as  given  by 
Holden  I  regard  as  too  high,  but  the  difference  in  our  views  is  not, 
after  all,  a  very  material  one. 


*  Edition  of  1901,  p.  li 


l8  Diagnosis  of  Heart  Diseases 

Seen  from  behind,  the  npijcr  level  of  the  heart  corresponds 
•\\  ith  the  center  of  the  4th  dorsal  vertebra,  and  the  lower  margin  of 
rtlie  5tli  rib,  on  the  left  side;  the  ni:)per  margin  of  the  6th  rib  on  the 
right  side.  The  apex  is  opposite  the  Sth  left  interspace,  abont 
midway  between  the  spines  of  the  vertebra;  ami  the  free  border  of 
the  ribs.  The  mitral  valve  is  opposite  the  6th  interspace,  close 
to  the  left  margin  of  the  6th  dorsal  vertebra.  The  aortic  lies  to 
the  left  of  the  median  line,  opposite  the  point  where  the  5th  dorsal 
«pine  overlaps  the  6th  ;  the  pulmonary  lies  between  them  ;  the  tricus- 
]iid  covers  the  median  line,  though  slightly  more  to  the  left  than  the 
right,  and  is  opposite  the  root  of  the  spine  of  the  6th  dot  sal  verte- 
t.ra  (Fig.  4). 

In  considering  heart  murmurs  the  physiological  action  of  the 
'heart  must  be  taken  into  consideration.  The  movement  of  the 
'blood  is  caused  by  the  contraction  of  the  auricles,  ventricles  and 
vessels.  The  blood  enters  the  auricles  by  the  veins,  and  then  is 
■ex])elled  by  the  auricles  through  the  auriculo-ventricular  open- 
ings or  valves  into  the  ventricles;  when  the  ventricles  are  filled, 
they  contract  and  force  this  blood  back  into  the  vessels,  the  left 
ventricle  driving  a  column  of  blood  through  the  aorta  into  the 
.greater  or  systemic  circulation  :  the  right  \entricle  driving  an- 
•other  column  of  blood  into  the  lesser  or  pulmonary  circulation. 
'Then  follows  a  contraction  of  the  great  vessels,  the  aorta  and 
pulmonary  artery.  In  health  the  action  of  the  ventricles  in  clos- 
ing is  attended  with  a  sound  or  tone,  due  to  three  principal 
causes;  i.  The  closure  of  the  auricular-ventricular  orifices.  2.  The 
muscular  action  of  the  ventricles.  3.  The  vibration  of  blood  in  the 
ventricles.  Roth  auricles  and  great  vessels  contract  during  the  filling 
of  the  ventricles  (diastole)  and  hence  any  sound  produced  during 
this  period  is  called  diastolic,  but  they  are  not  synchronous,  the 
vessels  contracting  at  the  beginning  of  diastole,  and  the  auricles 
at  the  end.  A  systolic  sound  is  produced  during  the  contraction 
of  the  ventricles  (systole),  and  the  word  presystolic  is  accepted 
as  indicating  a  sound  produced  at  the  end  of  diastole,  or  during 
the  contraction  of  the  auricles :  or  in  fact,  any  sound  not  produced 
during  the  time  for  the  contraction  of  the  aorta.  The  second 
sound  is  chiefly  due  to  the  closure  of  the  aortic  and  pulmonary 
valves,  and  the  vibration  of  blood  in  the  aortic  and  pulmonary 
arteries.  "Valves,  muscular  action,  chordse  tendinge,  vessels  and  the 
vibration  of  the  blood,  produce  heart  sounds. 

Now,  supposing  the  time  occupied  by  these  actions  were  di- 
•  vided  into  eighths,  one-eight  would  be  occupied  by  the  contrac- 


Diagnosis  of  Heart  Diseases 


19 


tion  of  the  lari;-c  vessels  and  auricles,  three-eighths  by  the  contrac- 
tion of  the  veiilt  icles ;  the  remaining-  four-eighths  or  one-half,  by  the 
filling  of  the  auricles  and  ventricles. 

The  following  diagram   illustrates  the   rhythm   of  the  heart 
under  normal  conditions: 


D  S  D  S 

Fig.  5.     Vicrordt. 


When  we  listen  at  the  apex  or  at  the  ensiform  cartilage  the 
first  sound  will  be  more  accentuated,  as  in  Fig.  6. 


S  D  S  D  S  D  S 

Fig.  6.     Vierordt. 

On  the  other  hand,  if  we  listen  at  the  base,  the  second  sound 
will  be  most  accentuated,  as  in  iMg.  7. 


S         D  S 

Fig.  7.     Vierordt, 


In  health  the  sounds  are  modified,  as  to  intensity,  by  the  elas- 
ticity of  the  chest,  thickness  of  superimposed  tissue,  especially 
by  fat,  and  in  women  by  the  breasts,  and  in  all  by  age.  Sharp  accent- 
uation of  the  second  sound  is,  if  continuous, a  very  sure  sign  of  hyper- 
trophy of  the  corresponding  ventricle.  And  it  is  particularly  impor- 
tant as  related  to  the  second  pulmonary  sound,  which,  if  accen- 
tuated, means  dilatation  and  hypertrophy  of  the  right  ventricle. 
In  arterio-sclerosis  of  the  aorta,  the  second  aortic  sound  may  be 
slightly  resonant  or  bell-like.  And  yet  when  there  is  heart  fail- 
ure the  accentuation  of  the  second  sound  fails.  But  all  heart 
sounds  are  more  or  less  faint  in  heart  failure,  pericardial  afTec- 


20 


Diagnosis  of  Heart  Diseases 


tions  and  emphysema.  In  valvular  affections  the  heart  sounds 
are  replaced  by  nnirmurs. 

The  tick-tack  rhythm  is  known  as  the  embryo  cardial  or  pendulum 
rhythm,  and  is  abnormal  in  the  fcetus. 

The  heart  sounds  may  be  doubled  or  trebled,  as  is  shown  in 
the  following  dia.c^ram  (  Fig.  8)  : 


Fig.  8.    Vierordt. 
Sometimes  there  is  a  triple  rhythm  as  in  Fig.  9. 


s  s 

Fig.  9.     Vierordt. 


I  heard  a  triple  rhythm  as  in  Fig.  10 


S  S 

Fig.  10. 

W'ith  Dr.  Dudley  in  1901,  when  the  patient  was  in  a  very  weak 
state  after  laparotomy,  and  when  there  was  a  short  beat  followed 
by  a  long  one,  in  the  radial  pulse. 

Or  we  may  have  a  gallop  rliyihiii,  as  shown  by  the  following 
diagrams,  but  this  is  not  always  a  pathological  condieitn. 


S  s  S 


s  s 

Fig.  II.    Vierordt. 


Diagnosis  of  Heart  Diseases  21 

Potain  claims  that  some  divisiun  of  the  sounds  occurred  in  20% 
of  persons  he  examined.  In  99  of  his  cases  the  first  sound  was 
divided  in  61  instances ;  the  second  sound  in  30 ;  in  8  both  were 
divided.  He  thinks  division  is  caused  by  respiration ;  that  the  di- 
vision of  the  first  sound  is  associated  with  the  end  of  expiration  and 
the  beginning  of  inspiration ;  division  of  the  second  with  the  end 
of  inspiration  and  the  beginning  of  expiration. 

A  murmur  either  supplants  a  tone  (sound)  or  co-exists  with 
it.  Sometimes  murmurs  replace  both  tones.  Occasionally  mur- 
murs are  so  loud  that  they  can  be  heard  at  a  distance  from  the 
patient.  Others  can  only  be  heard  with  the  greatest  dif^culty. 
In  fact,  very  slight  murmurs  may  only  be  elicited  by  movements 
of  the  body ;  or  if  the  patient  runs  around  the  room. 

Patients  should,  if  practicable,  be  examined  both  in  the  recum- 
bent and  upright  positions.  Sometimes,  murmurs  cannot  be  heard 
in  the  upright  position,  and  only  if  the  patient  lies  on  the  right 
or  left  side.  Mitral  lesions  are  often  best  heard  when  the  patient 
is  recumbent. 

Murmurs  are  divided  into  : 

1.  Vakmlar  and 

2.  Accidental. 

Under  the  latter  are  included  those  that  are  disconnected  with 
valves,  papillary  muscles,  and  chordae  tending.  They  are  due  to 
altered  conditions  of  nutrition  in  the  heart  muscles,  or  alterations 
in  the  quality  or  constitutents  of  the  blood,  and  are  found  exclu- 
sively during  systole,  and  at  any  single  valve ;  often  at  all 
valves  together ;  usually  with  slighter  murmurs  in  the  vessels  of 
the  neck,  of  a  light  blowing  character.  But  most  important,  from 
a  diagnostic  point  of  view,  is  that  all  the  consequences  of  valve  de- 
fects are  absent  in  these  accidental  cases.  The  exciting  causes  are 
chiefly  anaemia,  or  some  form  of  blood  deficiency,  fever,  cancer, 
consumption,  or  pressure  of  neighboring  organs  on  the  heart.  In 
pernicious  anaemia  the  murmurs  are  very  loud. 

Any  kind  of  diminution  in  heart  pressure  also  causes  accidental 
murmurs.  Less  often  they  are  caused  by  transitory  disturbances 
of  the  functions  of  the  m3^ocardium,  or  the  papillary  muscles,  causing 
temporary  insufficiency  of  the  valves.  Other  accidental  sounds  may 
be  caused  by  the  act  of  respiration. 

Corresponding  to  the  four  valves  of  the  heart  there  are  nor- 
naally  four  tones  or  sounds,  and  as  each  valve  ma}'  leak,  we  have  four 
additional  sounds,  making  eight  in  all. 


22 


Diagnosis  of  Heart  Diseases 


A  iininmir  is  tlie  name  given  to  an  atlvontitious  sound  heard 
in  connection  w  itli  the  heart  sound,  when  there  is  \  alvuhir  endo- 
carditis or  valve  distortion.  Aluruiurs  vary  in  fyitcli,  quality,  duration 
and  intensity.  They  are  charactertistic  of  valvular  diseases,  but  may 
be  absent,  and  are  not  always  heard  (5  per  cent.)''.  Endocardial 
murmurs  must  be  carefully  disting^uished  from  j^ericardial  and 
respiratory  sounds.  Respiratory  sounds  are  limited  to  inspira- 
tion, so  that  in  order  to  eliminate  them,  the  patient  should  hold  his 
breath.  An  endocardial  murmur  is  synchronous  with  systole  or 
diastole,  and  is  deep  seated.  A  pericardial  murmur  is  heard  over 
any  part  of  the  heart,  but  is  best  heard  at  a  distance  from  the 
valves  or  apex.  It  is  a  sound  that  is  very  near  the  ear.  Pressure 
by  the  stethoscope  increases  pericardial  friction  sounds,  but  does 
not  affect  the  endocardial. 

None  of  the  valve  sounds  are  best  heard  immediately  over  the 
valves,  because  the  sound  is  conducted  in  all  cases  to  the  sur- 
face, along  the  line  of  the  flowing  blood  current ;  but  the  pulmon- 
ary, being  nearest  the  surface,  is  heard  best  at  points  just  above 
or  below  the  valve,  and  so  the  tricuspid ;  while  the  aortic  and  mi- 
tral, for  similar  reasons,  are  best  heard  at  points  remote  from  the 
valves. 

We  find,  accordingly,  that  the  pulmonary  obstructive  murmur  is 
best  heard  at  the  junction  of  the  26.  left  interspace  with  the  sternum. 


Fig.  12. 
According  to  my  figures. 


Fig.   13. 


Diagnosis  of  Heart  Diseases 


23 


or  above  its  actual  position,  and  is  conducted  upwards.  (y^g.  15.) 
The  pulmonary  regurgitant  murmur  is  heard  a  little  below  this  point 
and  is  conducted  downwards ;  but  as  the  pulmonary  valve  is  the 
most  superficial  of  all,  the  sounds  are  always  near  the  ear.     (Fig. 


Fig.  14. 


Fig.  15. 


14.)  The  aortic  obstructive  murmur  (Fig.  12)  is  best  heard  over 
a  somewhat  larger  area  than  the  pulmonary  and  at  the  junction 
of  the  3d  right  cartilage  with  the  sternum,  and  the  sounds  are 
conducted  upwards  chiefly.  The  aortic  regurgitant  murmur  is- 
also  best  heard  somewhat  below  the  normal  position  of  the  valve 
and  at  the  junction  of  the  4th  left  costal-cartilage  with  the  ster- 
num. This  murmur  is  conducted  chiefly  towards  the  ensiform 
cartilage,  nipple  and  apex,  but  to  a  slight  extent  also  in  the  re- 
verse direction  (Fig.  13).  I'he  mitral  obstructive  murmur  is 
heard  best  at  a  still  more  remote  distance,  viz.,  over  a  limited 
area  above  the  apex,  usually  about  midway  between  the  ensiform- 
appendix  and  the  nipple.  The  area  of  mitral  stenosis,  however, 
is  not  always  well  defined.  Occasionally,  but  still  rarely,  the 
murmur  of  mitral  obstruction  may  be  heard  over  any  part  of  the 
shaded  area  marked  M   (Fig.  15). 

The  mitral  regurgitant  murmur  (Fig.  14)  is  heard  at  the 
point  farthest  from  the  valve  of  all,  viz.,  over  the  apex."  But  the 
murmur  is  conveyed  to  the  left,  not  uncommonly  to  the 
axilla,  and  sometimes  to  the  scapula,  a  matter  not  hard  to  under- 
stand by  aid  of  Fig.  4 ;  for  not  only  in  dilated  hearts  may  the  bor- 


24  Diagnosis  of  Heart  Diseases 

der  of  the  heart  reach  to  the  scapula,  hut  the  hlood  current,  from  the 
position  of  the  mitral  in  the  back  of  the  thoracic  cavity,  and  the 
direction  of  its  current  must  necessaril}'  cause  the.  murmur  to  be 
carried  to  the  back.  The  mitral  area  is  indicated  by  the  large  letter 
M   (Fig.   15). 

In  tricuspid  obstruction  the  murmur  is  usually  heard  best 
along  the  left  border  of  the  ensiform  appendix  at  the  points  in- 
dicated by  the  small  letters  0  0  (Fig.  15).  The  regurgitant  murmur 
is  best  heard  over  the  sternum,  mostly  at  the  junction  of  the  5th 
left  costal  cartilage  with  the  sternum,  but  occasionally  also  on  the 
opposite  side.  It  is  indicated  by  the  small  letters  r  r  r  (Fig. 
15).  The  fricitsf'id  area,  however,  is  a  large  one,  and  in- 
definite. It  is  indicated  by  the  shaded  area  over  which  is 
the  large  letter  T  (Fig.  15).  But  it  must  be  remembered 
that  while  the  base  of  the  heart  is  tolerably  fixed  by  the  great 
vessels  and  structures  that  compose  its  root,  the  heart  itself 
is  apt  to  be  dilated  and  hypertrophied  both  in  endocardial  and 
myocardial  diseases,  so  that  the  relation  of  the  sounds  to  the 
bony  landmarks  of  the  thorax  will  vary  correspondingly.  Accord- 
ingly, the  meaning  of  these  sounds  must  be  read  in  connection  with 
other  objective  and  subjective  phenomena,  in  order  to  be  properly 
appreciated. 

No  examination  of  the  heart  should  be  made  without  at  the 
same  time  an  examination  of  the  lungs,  liver  and  spleen. 
Patients  are  often  seen  by  the  consultant  where  tuberculosis 
of  the  lungs  is  the  main  disease,  and  the  cardiac  a  secondary 
affair ;  most  of  the  symptoms  of  the  latter  depending  on  the  lung 
disease.  On  the  other  hand,  spitting  of  blood,  which  is  common 
in  some  forms  of  cardiac  disease,  ma}-  be  wrongly  attributed  to 
a  non-cardiac  lung  disease. 

The  liver  should  be  examined  for  size,  position  and  tender- 
ness. In  cardiac  diseases  it  is  apt  in  the  later  stages  to  extend 
below-  the  free  borders  of  the  ribs,  and  may  even  reach  the  um- 
bilicus. It  may  be  tender  to  the  touch.  Sometimes,  especially 
in  very  advanced  cases,  a  hob-nail  surface  can  be  felt.  In  one  of 
my  cases  of  enlarged  liver  the  left  lobe  pushed  uj)  the  heart  so 
that  the  apex  was  above  the  nipple. 

The  spleen  is  also  apt  to  be  enlarged  when  the  liver  is.  It 
is  often  the  seat  of  embolism,  and  as  in  case  No.  V,  may  have 
suppurative  infarcts. 

It  is  needless  to  sav  that  the  urine  should  ulwavs  be  examined. 


Diagnosis  of  Heart  Diseases  25 

Attention  to  the  digestion  is  also  imperative  in  the  management 
of  cardiac  diseases,  especially  in  persons  of  middle  life  and 
beyond.    Indigestion  alone  is  not  an  infrequent  cause  of  death. 

In  anaemia  there  is  the  venous  hum,  or  "bruit  de  diable."  This 
is  a  continuous  murmur  heard  over  the  internal  jugular  veins  at 
.the  root  of  the  neck,  but  it  is  not  pathognomomic  of  anaemia, 
as  in  50%  of  the  cases  where  it  has  been  observed  there  has  been 
none.  ,  It  is  often  of  a  musical  quality,  and  usually  more  distinct 
on  the  right  side.  The  intensity  of  the  murmur  is  increased  by 
the  upright  position ;  by  turning  the  head  away  from  the  side  which 
is  being  auscultated;  and  by  a  deep  inspiration.  It  is  also 
modified  by  the  pressure  of  the  stethoscope.  The  cause  appears 
to  be  some  alteration  in  the  calibre  of  the  vein,''  due  to  com- 
pres'sion  or  adhesions  attaching  it  to  surrounding  parts ;  or  it 
may  be  due  to  a  diminished  flow^  of  blood.  It  has  been  claimed 
in  some  of  these  cases  that  the  vein  is  "pouched,"  which  would 
account  for  the  murmurs.  The  venous  hum  is  not  heard  in  all 
cases  of  anaemia,  and  the  intensity  of  the  murmur  is  not  propor- 
tionate to  the  alteration  in  the  quantity  or  quality  of  the  blood.  In 
.anaemia  a  bruit  is  also  heard  over  otherveins.  A  continuous  murmur, 
described  as  being  like  the  wind  "blowing  through  the  rigging 
of  a  ship  under  bare  poles,"  is  also  sometimes  heard  on  either  side 
of  the  xiphoid  cartilage,  and  it  is  thought  to  indicate  constriction 
of  the  inferior  vena  cava.  In  anaemia  there  is  sometimes  a  sys- 
tolic murmur  in  the  pulmonic  area.  It  is  most  distinctly  heard 
in  the  2nd  left  intercostal  space,  close  to  the  sternum,  and  is  the 
most  constant  of  the  mvirmurs  associated  with  anaemia.  This  is 
said  to  be  due  to  dilatation  of  the  right  ventricle,  owing  to  mal- 
nutrition, without  change  in  the  pulmonic  orifice,  so  that  it  is 
relatively  narrowed,  and  therefore  capable  of  producing  a  mur- 
mur, as  in  organic  stenosis.  The  same  theory  holds  good  if  the 
heart  is  diminished  in  size,  as  it  often  is  in  anaemia.  For  in  such 
case  the  orifice  would  be  relatively  dilated  and  equally  capable 
of  producing  a  murmur.  There  are  other  theories,  such,  for 
example,  as  that  the  murmur  is  due  to  pressure  on  the  pulmonary 
artery  by  a  distended  left  auricle.  It  has  also  been  claimed  that 
the  murmur  is  due  to  dilatation  of  the  conus  arteriosus  and  pul- 
monary artery,  and  that  this  condition  is  to  be  found  at  the  post- 
mortem examination  of  patients  who  have  had  this  functional 
murmur  during  life.     This  view  seems  at  the  present  time  to  be 

°  Colbert,  Dis.  of  the  Heart,  London,  1901,  p.  72. 


26  Diagnosis  of  Heart  Diseases 

icasonablc,  but  it  rccjiiires  substantiation.  Tbe  mitral  systolic 
)iiiin)ittr  beard  in  some  cases  of  anjemia,  at  tbe  apex,  and  carried 
to  tbe  left,  even  to  tbe  angle  of  tbe  scapula,  is  due  to  regurgita- 
tion from  relaxation  of  the  muscular  fibres  about  tbe  mitral  ori- 
fice, so  that  the  valve  leaflets  do  not  come  into  proper  apposition. 
This  is  either  due  to  malnutrition  of  tbe  myocardium,  to  the  musculi 
papillares,  or  to  simple  dilatation  of  tbe  left  ventricle. 

The  tricuspid  systolic  niunuur  in  aniemia  is  beard  in  tbe  tri- 
cuspid area.  It  is  due  to  dilatation  of  the  right  \(.ntrick\  If 
the  anjemia  is  slight,  the  miu'nnn-  may  be  absent. 

Tbe  aortic  systolic  )inir}inir  in  anjemia  is  beard  in  the  aortic 
area,  and  is  thought  to  be  due  to  relative  narowing  of  tbe  aortic 
orifice  from  dilatation  of  the  left  ventricle.  In  these  so-called 
licDnic  imtrjiiurs  the  position  and  direction  of  tbe  murmurs  cor- 
respond with  those  of  the  organic  variety ;  but  they  are  usually  soft, 
and  are  not  conducted  so  far  as  in  the  latter  variety. 

Exocardial  sounds  may  be  mistaken  for  cardiac  murnnirs. 
Of  these  there  are  several  varieties.  In  health  there  is  no  soimd 
produced  by  the  heart  pressing  against  the  pericardium,  but  when 
either  surface  is  roughened  by  disease,  a  friction  sound  is  pro- 
duced. It  is  usually  best  heard  over  the  right  ventricle  and  the 
base  of  the  heart.  The  sound  is  limited  to  this  particular  area, 
and  is  like  that  of  two  bodies  rubbing  against  one  another.  It 
is  described  as  "grating,  creaking,"  etc.,  and  is  intensified  by 
pressure  with  the  stethoscope,  deep  inspiration,  or  changes  in  pos- 
ture. It  also  changes  its  position  from  time  to  time.  Tbe  sounds 
correspond  to  the  contraction  and  relaxation  of  the  ventricles. 

A  pleural  friction  sound  may  also  be  produced  b}-  tlic  move- 
ments of  the  heart,  but  it  ceases  when  the  breath  is  held. 


CllAl'TKK    IT. 

ENDO-CARDIOPATHIES.^ 

Endocardial  diseases  are  usually,  though  not  always,  localized 
about  the  valves,  and  may  or  may  not  be  inflammatory.  Conse- 
quently, the  word  endocarditis,-  sometimes  used  as  synonomous 
with  endocardial  diseases,  is  not  sufficiently  comprehensive.  A 
better  term  is  endocardiopathies,  which  adequately  includes  all 
endocardial  affections. 

Though  endo-cardiopathies  were  alluded  to  as  early  as  1684 
by  Thomas  Willis  in  his  "Practice  of  Physick,"  and  attracted 
the  attention  of  Merkel,  Senac  and  John  Hunter  in  the  century  fol- 
lowing, physicians  gave  them  little  attention,  until  exploited  by  Cor- 
visart  in  1808.  During  the  remainder  of  the  century,  however,  they 
were  studied  from  almost  every  available  point  of  view  by  such  men 
as  Kreysig,  Andral,  Corrigan,  Bouillaud,  Virchow,  Walshe  and 
Stokes,  American  physicians  contributing  in  later  years  valuable 
material. 

Affections  of  the  endocardium  constitute  about  one-half  of  the 
total  of  cardiac  diseases,  and  as  the  inflammator}-  differ  materially 
from  the  non-inflammatory  in  etiology,  prognosis,  and  treatment 
so  we  may  classify  them  on  this  basis ;  or,  on  the  other  hand,  ma} 
divide  them  into  the  primary  (i.  e.,  inflammatory),  under  which  fall 
the  vegetative,  infiltrative,  ulcerative,  stenotic  or  sclerotic  varie- 
ties, as  distinguished  from  the  secondary  {i.  e.,  non-inflamma- 
tory), where  the  changes  are  secondary  to  the  former,  and  are  such 
as  are  caused  by  the  mechanical  stretching  of  the  muscular  or  fibrous 
tissues. 

Some  have  adopted  the  plan  of  classifying  them  on  the  basis 
of  their  alleged  causes.  Thus  Litten  (Phila.  Med.  Jour.,  May  5th, 
1900)  has  distinguished  a  rheumatic,  scarlatinal,  typhoid  and 
pneumonic  endocarditis,  etc.,  but  lately  we  have  discovered  that 
endocarditis  follows,  and  appears  to  be  caused  by,  a  number  of  dis- 
eases of  less  moment,  such  as  coryza,  diseases  of  the  skin,  and  gas- 
tro-intestinal  disorders.  A  more  simple  method  is  to  separate  endo- 
cardiopathies into  the  acute,  sub-acute  and  chronic. 


^Originally  published  in  the  Virginia  Aled.  Semi-Moitthly.  April  26.  1901. 
^Introduced  by  Bouillaud  in  1841. 


28  Endo-Cardiopathies 

The  coincident  relations  of  tlie  various  i)iicro-organis}iis  to 
the  endocardial  inflammations  have  been  frequently  noted,  and 
cultures  have  produced  endocarditis  in  the  rabbit.  But  the  va- 
riety of  these  organisms  is  confusing;.  In  1886  Weichselbaum 
distinguished  tw^o  varieties,  the  staphylococcus  pyogenes  aureus, 
and  the  streptococcus.  Netter  found  the  diplococcus  of  Frsenkel ; 
others  have  found  the  bacterium  coli ;  others  the  gonococcus  of 
Xeisser,  etc.  But  Michaels  (Phil.  Med.  Jour.,  May  5th,  1900), 
opened  a  number  of  rheumatic  joints  and  found  no  micro-organ- 
isms. Still,  notwithstanding  this  divergence  of  opinion  there  i.s 
reason  to  believe  that  some  forms  of  endocarditis  are  of  microbic 
origin. 

Acute  rheumatism  is  generally  taken  to  be  the  chief  cause  of 
endocarditis.  In  fully  40  per  cent,  of  my  cases  there  was  an  ante- 
cedent history  of  rheumatism,  and  as  many  as  one-third  of  the 
cases  of  acute  rheumatism  I  have  found  were  followed  by  endocardi- 
tis. These  are  conservative  figures  in  the  light  of  statistics  that 
follow. 

And  }et,  figures  do  not  always  have  much  significance  when 
rheumatism  is  concerned,  because  the  word,  both  with  the  laity 
and  physicians,  is  loosely  applied.  However,  Latham  found  that 
in  136  cases  of  acute  rheumatism  the  valves  were  affected  in 
seventy-four,  or  54  per  cent.,  Gibson  in  184  out  of  325  cases,  or 
56  per  cent.   (Gibsoiis  Diseases  of  the  Heart,  1898,  p.  397). 

In  this  connection  it  is  interesting  to  observe  that  chorea  has 
a  close  genetic  relation  with  acute  articular  rheumatism  and  that 
Fagge  found  few  fatal  cases  of  chorea  without  organic  valvular 
changes  similar  to  those  of  rheumatic  endocarditis. 

There  is  also  a  manifest  relation  between  the  age  of  a  patient 
and  the  initial  attack  of  rheumatic  endocarditis.  For  example, 
when  infants  or  children  have  an  acute  attack  of  rheumatism, 
they  are  liable  to  endocarditis,  perhaps  in  70  per  cent. ;  and  yet 
acute  rheumatism  is  rare  in  infancy  and  young  life,  though  com- 
paratively common  in  the  decenniums  between  30  and  50.  After 
this  period  it  rarely  develops. 

There  is  no  rule  as  to  the  date  at  w^hich  endocarditis  appears 
in  acute  articular  rheumatism.  It  may  occur  at  any  time  during 
the  attack,  or  may  precede  it.  After  rheumatism,  pneumonia  fol- 
lows as  one  of  the  most  frequent  causes  of  endocarditis.  The 
loxin  of  the  pneumococcus,  however,  administered  to  rabbits 
■bv    Carnot    and    Fournier    {Arch,    dc    Med.    Exp.,    XII,    p.    357, 


Endo-Cardiopathies  29 

Schmidt's  Jahrbuch),  was  followed  by  acute  inflammation  of 
the  heart  muscles,  intestinal  haemorrhages,  dej^eneration  and 
fragmentation  of  the  voluntary  muscles,  while  the  valves  were 
not  affected. 

Gibson,  on  the  other  hand  (Edinb.  Med.  Jour.,  Nov.,  1900J, 
has  reported  a  case  of  diplococcal  infection  resulting  in  pleuro 
pneumonia.  At  the  autopsy  the  aortic  segments  were  seen  to  be 
ulcerated,  and  in  a  thrombus  adherent  to  the  aortic  valves 
there  were  found  diplococci,  leucocytes  and  fibrin.  Endocarditis 
is  quite  often  found  in  tuberculosis,  but  the  cause  of  the  disease 
has  been  usually  attributed  in  these  cases  to  a  streptococcus, 
staphylococcus,  Fraenkel's  pneumococcus,  or  Friedlander's  cap- 
sule bacillus. 

Endocarditis  is  also  frequently  associated  with  surgical  dis 
eases,  such  as  osteomyelitis,  erysipelas,  dysentery,  pyaemia  and 
septicaemia,  puerperal  fevers,  and  furunculosis :  and  the  staphy- 
lococcus pyogenes  aureus  has  been  most  frequently  found  asso- 
ciated with  the  lesions  of  these  affections.  In  erysipelas,  an  asso- 
ciated endocarditis  has  been  traced  to  a  streptococcus,  and  with  it 
endocarditis  has  been  produced  experimentally  by  a  number  of 
workers.  In  gonorrhoea!  endocarditis  Leyden  found  the  gono- 
coccus  of  Neisser  in  the  valvular  deposits.  They  had  the  dis- 
tinct biscuit  form,  and  were  colored  satisfactorily  by  Gram's 
method. 

In  scarlatina,  endocarditis  was  seen  to  develop  by  Trousseau^ 
and  others.  It  may  occur  at  any  time  during  the  disease  or  with 
its  sequelae.  But  a  characteristic  micro-organism  has  not  been 
found,  as  yet,  in  this  form.  Influenza  afifects  the  heart  in  many 
ways,  but  chiefly  attacks  the  muscular  substance,  through  the 
poisonous  influence  of  the  toxins  ;  though  endocarditis  has  been 
attributed  to  influenza.  Endocarditis  occurs  occasionally  in  var- 
iola, but  if  the  primary  disease  is  severe,  the  cardiac  affection  is 
(as  often  happens  in  endocarditis)  associated  with  other  affec- 
tions, such  as  a  myopathy  or  pericarditis.  Endocarditis  occurs 
occasionally  in  measles,  but  syphilis  rarely  attacks  the  valves, 
though  the  myocardium  is  occasionally  involved.  While,  as  al- 
ready stated,  many  different  sorts  of  micro-organisms  have  been 
found  in  the  ulcerated  valves,  the  etiological  relation  they  hold 
to  the  diseased  condition  is  still  doubtful.  This  problem  may 
eventually   be   settled   by   determining   whether   or  not   the   micro- 


Trousseau,  Clin.  Med.,  vol.  2,  1869,  p.   i{ 


30  Endo-Cardiopathies 

i^rg^anisms   arc    to    be    found    in    the    Initial    lesions    of   the    valves. 

There  is  a  close  relation  between  endocarditis  and  some  fvuin> 
of  Brig;ht's  disease.  Inasmuch,  however,  as.  according-  to  my  in- 
vestigations.'' Htlu-emia  is  a  causal  factor  of  Bright's  disease  in  from 
50  per  cent,  to  75  per  cent.,  the  close  relation  between  rheuma- 
tism and  endocarditis  is  plainly  shown.  But  Bright's  disease  is 
apt  to  be  a  late  phenomenon  in  endocarditis. 

Endocarditis  is  most  frccjuent  after  ten  and  before  forty,  but 
there  is  a  manifest  relation  between  the  age  of  the  patient  and 
the  seat  of  the  disease.  In  the  foetus,  the  right  side  of  the  heart, 
doing  the  most  work,  is  most  frequently  aflfected ;  in  extra- 
uterine life  it  is  the  left  heart,  for  similar  reasons.  Accordingly, 
age  and  the  character  of  work  to  be  done  must  be  considered  in  es- 
timating the  liability  to  endocarditis.  In  extra-uterine  life,  dis- 
ease affects  the  mitral  or  aortic  valves  b}'  preference,  next  the 
pulmonary  and  tricuspid  valves,  but  these  latter  in  a  compara- 
tively small  number  of  instances.  There  is  little  difference  in 
the  tendency  to  endocarditis  between  men  and  women,  though 
it  is  generally  held  that  mitral  disease  is  more  common  in  women 
and  aortic  in  men. 

The  beginning  of  an  endocarditis  is  marked  by  an  invasion  of 
the  substance  of  the  valves  by  toxins,  micro-organisms  and  in- 
flammatory exudates,  wdiile  on  their  surfaces  the  shining  endothe- 
lium becomes  opaque  and  gives  birth  to  minute  rounded  flesh 
colitred  papillary  bodies,  which  are  one  or  two  millimeters  in 
height  when  first  seen,  and  situated  near  the  free  edges  of  the 
valves.  On  the  mitral  they  develop  on  the  auricular  surfaces  at  a 
distance  of  2-3  millimeters  from  the  free  edge,  while  on 
the  aortic  they  form  on  the  ventricular  surfaces.  They  are  at  the 
point  of  maximum  contact.  To  these  excrescences  are  at- 
tached particles  of  fibrin  from  the  blood,  and  these,  together  with 
ulcerated  portions  of  the  valves,  may  be  carried  into  the  general 
circulation  and  cause  embolism.  There  are  all  degrees  of  infdtra- 
tion  in  these  valves,  with  or  without  ulceration,  and  the  disease 
may  extend  and  involve  the  myocardium.  But  wherever  ulcera- 
tion takes  place,  there  is  at  the  same  time  a  sclerotic  chang-- 
coincident  with  it,  so  that  destructive  and  constructive  processes 
go  hand  in  hand,  nature  attempting  to  repair  as  disease  destroys. 

Pathologically,  the  changes  consist,  first,  in  a  thickening  of 
the  small  vessels,  with  hyaline  degeneration  and  perhaps  partial 
sclerosis  of  the  smaller  arteries,  followed  bv  a  small-celled  infiltra- 


*.Y.   )'.  Med.  Rec,  March  7,  1889. 


Endo-Cardiopathies  3 1 

lion  and  proliferation  of  connective  tissue,  with  eventual  destruc- 
tion of  muscle  cells.  The  process  may  be  so  extensive  that  the 
greater  part  of  a  valve  is  destroyed  or  even  converted  into  an 
aneurismal  sac.     I  have  seen  an  example  of  the  latter  accident. 

In  the  chronic  forms,  there  is  often  a  deposit  of  the  salts  of 
lime  in  the  valves,  or  along  their  attached  margins,  and  the  pro- 
cess extends  down  over  and  into  the  chordae  tendinse,  contracting 
and  stiffening  them,  while  the  papillary  muscles  are  also  apt  to 
undergo  fatty  and  calcareous  degeneration.  Such  stiffened  por- 
tions of  the  endocardium  occasionally  rupture. 

Endocarditis  develops  insidiously,  as  a  rule.  It  may  not  be 
discovered  unless  looked  for.  Years  often  pass  before  it  is  recog- 
nized. Much  depends  on  the  situation.  If  confined  to  the  walls 
•of  the  heart  it  seldom  shows  any  signs.   I  have  seen  a  few  such  cases. 

It  is  interesting  to  know  exactly  what  is  found  in  valvular 
■diseases  at  autopsies,  and  the  tables  of  Sperling  prepared  from 
the  Records  of  the  Berlin  Pathological  Institute  between  i868-'70, 
are  the  best  I  have  met  with.  They  may  be  compared  with  my 
•own  tables  of  a  smaller  number  of  cases  arranged  on  the  same  plan. 

Sperling's  Tables.'^ 

300  Cases  of  Endocarditis.     1868-70. 
268  cases  :rr  89  per  cent,  left  side  of  heart. 
3  cases  z=^     I  per  cent,  right  side  of  heart. 
29  cases  =z  10  per  cent,  both  sides  of  heart. 

300  100 

Affections  of  One  I'akx  Only. 
200  Cases  =;  66.7  per  cent. 

Mitral  valve  only 157  cases  r=  78.5  per  cent. 

Aortic  valve  only 40  cases  :=:  20.     per  cent. 

Tricuspid   valve   only 3  cases  z=  1.5  per  cent. 

Pulmonary  valve  only o  cases  =  0.0  per  cent. 

200  loo.o  per  cent. 
Combined   J\ilvular  Lesions. 
100  Cases  =  ^3.3  per  cent. 

Mitral   and   aortic... 71  cases  z=z  71  per  cent. 

Mitral  and  tricuspid 9  cases  1=  9  per  cent. 

Mitral  and  pulmonary 2  cases  r=  2  per  cent. 

Aortic  and  pulmonary i  case  zz:  i  per  cent. 

f           Aortic  and  tricuspid o  case  z=  o  per  cent. 

Mitral,  aortic  and  tricuspid 16  cases  z=  16  per  cent. 

Mitral,  aortic  and  pulmonary o  case  izz:  o  per  cent. 

-Tricuspid,  pulmonary  and  mitral o  case  ^=  o  per  cent. 

Tricuspid,  pulmonary  and  aortic o  case  =r  o  per  cent. 

All  four  valves i  case  z=  1  per  cent. 


Gibson's  Dis.  of  the  Heart  and  Aorta.    1898,  p.  413. 


TOO  100  per  cent. 


32  Endo-Cardiopathies 

Einholisin. 
84  Cases  =  28  per  cent. 
;()  with  left  side  disease — 8  with  right  side  disease. 
Kidney,  57. 
Spleen,  39. 
Brain.   15. 

Digestive  organs,  5. 
Skin,  4. 

Author's  Tables. 
6s  Cases  of  Endocarditis,  1872- 1888. 
56  cases  rr  86  per  cent,  left  side  alone  affected. 
o  cases  =z     o  per  cent.  ri}.;ht  side  alone  affected. 
9  cases  =z  14  per  cent,  both  sides  affected. 

65  100  per  cent. 

Affections  of  One  Valve  Only. 
18  Cases  =  27  per  cent. 
Mitral  valve  only 6  cases  nr  33.33  per  cent- 
Aortic  valve  only 12  cases  r=  66.67  P^r  cent. 

(Including  diseases  of  ascending  portion  of  arch) 

Tricuspid  valve o  case     zzz     0.0    per  cent. 

Pulmonan,-  valve o  case     zzn     0.0     per  cent. 

18  loo.o  per  cent.. 

Combined   I'aii'ular  Lesions. 
44  Cases  =  67  per  cent. 

Mitral  and  aortic 31  cases  zzr  70.5  per  cent. 

Mitral  and  tricuspid 2  cases  ^:  4.5  per  cent.. 

Mitral  and  pulmonary 0  case  ;rr  CO  per  cent. 

Aortic  and  pulmonary o  case  zz:  0.0  per  cent.. 

Aortic  and  tricuspid 2  cases  zr  4.5  per  cent. 

Mitral,  aortic  and  tricuspid 4  cases  ^  9.4  per  cent. 

Mitral,  aortic  and  pulmonary i  case  =  2.2  per  cent.. 

Tricuspid,  pulmonary  and  mitral....       i  case  :=z  2.2  per  cent. 

Tricuspid,  pulmonary  and  aortic o  case  :=:  0.0  per  cent. 

All    four   valves i  case  =z  2.2  per-cent. 

Pulmonary  and   tricuspid 2  cases  =z  4.5  per  cent. 

44  100    per  cent. 

Embolism. 
1 1  Cases  z=   16  per  cent. 

All  occurred  in  connection  with  left  side  disease  and  as- 
follows : 

Kidney,  6  times. 

Spleen,  4  times. 

Brain,  once. 

Liver,  twice. 

It  will  be  noticed  that  there  is  a  general  agreement  between' 
the  two  tables,  except  as  to  the  comparative  frequency  of  aortic 
and  mitral  diseases.  Probably  in  my  tables  a  larger  number  of 
cases  would  have  altered  this  relation. 

If,  however,  in  my  65  cases  we  throw  out  the  affections  of  the  first 
part  of  the  aorta,  the  incidence  upon  the  valves  stands  as  follows: 


Endo-Cardiopathies  33 

..  Aortic  insufficiency  49  times 

2.  Aortic  obstruction 39 

3.  Mitral   insufficiency   38 

4.  Mitral   obstructions   33 

5.  Tricuspid   insufficiency    8 

6.  'Jricuspid   obstruction    4 

7.  Pulmonary  insufficiency    4 

175 

But  as  single  valve  lesions  were  rare,  the  total  foots  up  175,  a« 
average  of  from  two  to  three  valve  lesions  in  each  case.  The  fol- 
lowing is  the  order  of  frequency,  as  recorded  in  my  office  cases : 

Aortic  disease  56  per  cent. 

Mitral  disease  35  per  cent. 

Tricuspid  disease 6  per  cent. 

Pulmonary  disease 3  per  cent. 

100  per  cent. 

On  the  other  hand,  in  50  cases  from  my  clinic,  as  taken  by 
imyself  and  assistants  (not  verified  by  post-mortems),  the  inci- 
dence was  put  down  as  follows : 

1.  Mitral    insufficiency. 

2.  Aortic   insufficiency. 

3.  Aortic    obstruction. 

4.  Mitral   obstruction. 

5.  Tricuspid    insufficiency. 

6.  Pulmonary   insufficiency. 

This  is  not  very  unlike  the  order  of  Walshe  (Diseases  of  the 
Heart,  London,  1873,  P-  ^^05),  which  is — 

1.  Mitral    insufficiency. 

2.  Aortic  stenosis. 

3.  Aortic   insufficiency. 
,4.  Mitral  stenosis. 

5.  Tricuspid  regurgitation. 

6.  Pulmonary  incompetency. 

7.  Tricuspid    stenosis. 

Dr.  George  S.  Middleton,''  of  Glasgow,  puts  the  order  of  fre- 
.quency  from  his  dispensary  cases  (unsupported  by  post-mor- 
tems) as — 

1.  Mitral    insufficiency. 

2.  Mitral    stenosis. 

3.  Aortic  incompetenc}'. 

4.  Aortic   stenosis. 

5.  Tricuspid  disease 

6.  Pulmonary  disease. 

"Lancet,  Oct.  26,  1889. 


34  Endo-Cardiopathies 

And  yet  I  should  prefer  not  to  take  any  purely  clinieal  evi- 
dence as  a  basis  of  statistics,  for  the  following  reasons : 

In  my  65  cases  with  clinical  histories  and  post-mortems,  while 
endocardial  disease  was  recognized  by  those  who  had  charge  of 
the  patients' in  95  per  cent.,  37  cases  of  aortic  disease  were  only 
noted  in  27,,  or  62  per  cent. ;  while  in  31  cases  of  mitral  disease,  it 
was  detected  in  only  19.  or  ()i  ])er  cent.  In  other  words,  there 
was  a  positive  failure  to  locate  in  39  per  cent,  of  actual  lesions. 
This  revelation  of  the  results  of  actual  experience  in  hospitals, 
where  the  physicians  were  among  the  best  we  have  had,  shows  how 
futile  it  is  to  base  conclusions  on  clinical  evidence  only.  And  yet  up 
to  this  time  it  has  been  the  main  stay  of  clinicians.  On  the  other 
liand,  it  is  expecting  too  much  to  require  a  physician  to  differentiate 
•every  valvular  lesion  at  the  bedside,  or  in  the  consulting  room.  As 
the  best  clinicians  often  fail  to  recognize  them  now.  so  the}-  will  con- 
tinue to  do  for  all  time.  The  reasons  are  threefold.  In  many  in- 
stances they  give  no  sign,  or  if  they  do,  attendant  circumstances 
prevent  them  from  being  appreciated.  I  have  even  heard  a  dis- 
tinguished diagnostician  say  that  a  diagnosis  of  a  specific  valvular 
disease  made  at  a  first  examination  had  little  value.  The  truth  is 
that  in  well-established  forms  of  organic  valvular  disease  a  specific 
diagnosis  can  usually  be  made  correctly  at  a  single  examination  ; 
while  in  less  pronounced  cases  several  examinations  may  be 
necessary. 

As  Stokes  said,  in  1855,  "The  difficulties  of  special  diagnosis 
are  still  infinitely  greater  than  many  might  be  led  to  expect." 
But  of  course  we  shall  gradually  overcome  some  of  these  difficulties, 
as  we  frame  better  rules  for  diagnosis. 

On  the  other  hand,  the  diagnosis  of  endocardial  disease,  on  the 
post-mortem  table,  is  comparatively  easy,  and  rarely  liable  to 
misinterpretation,  though  clinicians  do  not  all  take  this  view. 
The  chief  difficulty  lies  in  determining  whether  or  not  valves  are 
sufficient.  However,  the  ordinary  water  test  is,  I  think,  satis- 
factory, if  applied  by  an  experienced  pathologist ;  and  the  latte^ 
can  also  determine  whether  the  valve  affected  has  been  the  seat 
of  inflammation,  or  has  been  dilated  or  distorted  by  muscular 
action,  etc. ;  in  other  words,  whether  the  endocardial  disease  is 
primary  or  secondary. 

The  symptoms  of  an  acute  benign  endocarditis  are  variable  and 
inconstant,  and  may  escape  detection.  On  the  other  hand,  it 
may  be  announced  by  unmistakable  signs.     A  patient  is  seized 


Endo-Cardiopathies  35 

■with  intense  priecordial  pain,  dyspntx;a,  arrhythmia  or  rapid  pulse, 
perhaps  with  some  fever  or  even  cyanosis,  and  the  ear  applied  to 
the  chest  detects  a  rough,  loud  or  harsh  murmur.  Occasionally, 
the  suspicion  that  the  patient  is  having  an  acute  exacerbation  of 
the  chronic  disease  leads  us  to  apply  the  car.  More  rarely  a, sud- 
den strain  ruptures  a  valve  that  has  been  previously  softened  by 
infiltration,  or  made  brittle  by  atheroma  or  senile  changes.  Such 
an  event  is  usually  announced  by  a  musical  murmur.  An  acute 
attack  will  be  more  readily  detected  by  keeping  in  mind  the  var- 
ious affections  that  appear  to  cause  endocarditis.  In  the  actite 
septic  form  there  are  irregular  chills  and  sweats,  with  fever. 
•Other  signs  have  already  been  noted  as  belonging  to  the  benign 
form,  to  which  should  be  added  pretty  uniform  tenderness  and 
■enlargement  of  the  spleen,  with  sometimes  similar  conditions  of 
the  liver  and  kidneys.  The  urine  should  be  dark  colored ;  i.  e., 
.bloody,  if  a  kidney  develops  an  infarct. 

According  to  my  hospital  tables,  as  I  have  said,  endocarditis 
has  recognizable  murmurs  in  95  per  cent,  of  the  cases,  and  the 
three  most  prominent  signs,  following  the  auscultatory,  are  dysp- 
noea in  about  50  per  cent.,  palpitation  in  about  25  per  cent.,  and 
prsecordial  pain  in  about  10  per  cent.  Other  less  constant  symp- 
toms are  cough,  weak  or  irregular  action  of  the  heart,  dizzi- 
ness, epigastric  pulsation,  orthopnoea,  cyanosis,  delirium  and 
oedema.  In  only  5  per  cent,  there  were  no  characteristic  signs 
during  life.  But  as  I  have  said,  it  is  one  thing  to  be  able 
to  distinguish  endocarditis,  or  in  fact  any  endocardiopathy,  inflam- 
matory or  not.  and  quite  another  to  locate  the  precise  lesion  ac- 
curately. 

Of  the  endocardial  murmurs  there  are  two  kinds.  First,  the 
organic;  second,  the  functional.  The  former  are  heard  when 
there  is  a  mechanical  hindrance  to  the  flow  of  the  blood  from 
ulceration,  sclerosis  or  rupture  of  the  valve.  The  functional  mur- 
tnurs  are  caused  by  relative — i.e.,  muscular — insufficiency,  which 
•occurs  when  the  orifice  is  dilated  so  that  the  valve  margins  do 
not  come  together  accurately ;  or,  when  from  degeneration  oT 
weakness  of  the  papillary^  muscles,  the  valves  are  not  held  in 
place ;  also,  when  as  in  anaemia,  especially  in  convalescence  from 
long  continued  illness,  there  is  an  alteration  in  the  composition 
or  amount  of  the  blood.  An  irregular  pulse  with  praecordial  pain  and 
dyspnoea,  or  even  a  systolic  murmur  at  the  apex,  does  not  necessarily 
indicate  that  the  murmur  is  due  to  organic  disease ;  but  a  systolic 


2,6  Endo-Cardiopathies 

mnrniur  at  the  base  is  likely  to  be  functional,  if  it  is  liniiteil  to  the 
left  side  of  the  sternum,  and  there  is  no  thrill. 

Orijanic  nnirniurs  durini^  the  tlevclopment  of  an  endocarditis 
are  usually  harsh  and  loud.  The  I'rench  talk  about  the  sawing 
nnirmurs  (bruit  du  scic).  the  raspinc^  murnuir  (bruit  du  rape), 
the  musical  luurmur  {bruit  d'oboe),  the  bellows  nmrmur  (bruit  du 
souffle).  These  are  usually  organic;  functional  murmurs  are 
low,  soft  and  ahuuiys  systolic.  But  a  single  examination  luay 
not  suffice  to  distinguish  between  the  two.  The  organic  murmur 
will  be  more  apt  to  continue  ;  while  the  functional  will  disappear 
under  tonic  treatment  or  rest.  The  point  of  greatest  intensity  of 
a  murmur  is  somewhere  in  the  course  of  the  blood  current  beyond 
the  obstruction,  and  is  usually  due  to  the  breaking  up  of  the  cur- 
rent. Just  as  in  the  stream  of  water  flowing  through  a  narrow 
orifice,  it  is  not  at  the  point  of  greatest  obstruction  where  the 
noise  is  loudest,  but  where  the  water  expands  beyond  the  ob- 
struction, and  is  broken  up  into  diverse  currents.  When  a  blood 
current  passing  over  a  rough  surface,  or  through  a  narrow  pas- 
sage, can  be  felt,  the  sensation  is  called  a  "thrill,"  sometimes  a 
"purring  thrill."  {fremissement  cataire) ,  because  it  is  like  the 
thrill  felt  by  the  hand  pressing  on  a  purring  cat. 

In  endocarditis  we  do  not  always  need  to  be  alarmed  if  the 
pulse  is  frequent  or  infrequent.  Neither  condition  should  be 
treated  as  a  disease.  A  pulse  of  50  or  60  may  be  characteristic 
of  the  man,  and  so  a  pulse  of  100.  It  is  not  at  all  a  rare  thing  to 
find  a  patient  with  an  average  pulse  of  60 ;  but  it  is  uncommon  to 
find  a  pulse  of  100  or  more.  We  should  first  inquire  if  these 
abnormal  rates  of  the  pulse  are  not  individual  or  family  charac- 
teristics. I  have  known  the  most  serious  mistakes  to  be  made  in 
such  cases.  A  man  with  a  pulse  of  50  to  60,  or  even  120,  may  not 
reailize  that  there  is  anything  peculiar  about  the  action  of  his 
heart,  and  may  be  quite  as  able  to  do  his  daily  work  as  the  next 
man.  And  yet  physicians  are  quite  apt  to  treat  these  conditions, 
by  trying  to  bring  the  rate  to  the  recognized  average  of  seventy- 
two.  In  such  cases,  drugs  should  be  the  last  remedies  resorted 
to.  The  frequent  pulse  sometimes  follows  surgical  operations,  or 
injuries  to  the  thorax  or  neck. 

The  rhythm  is  usually  afifected  in  endo-cardiopathies,  both  in 
the  acute  and  chronic  forms,  and  always  in  broken  compensation. 
If  the  pulse  is  large,  it  generally  indicates  cardiac  hypertrophy; 
the  hard  pulse,  rolling  under  the  fingers,  means  arterio-sclerosis. 


Endo-Cardiopathies  37 

the  feeble  pulse  is  found  in  the  fatty  heart,  the  soft  pulse  in 
anaemia  and  in  fevers.  Pulsation  of  the  jugulars  suggests  tricus- 
pid regurgitation ;  the  capillary  pulse  aortic  regurgitation.  The 
pulse  may  be  unequal — that  is,  more  easily  felt  in  one  radial  than 
in  the  other — but  this  peculiarity  may  be  congenital  or  due  to  arterio- 
sclerosis, or  other  causes. 

The  sphygmo graph,  is  a  pretty  instrument,  but  it  is  less  used  than 
formerly,  because  it  is  apt  to  mislead.  It  is  of  value  in  clinical 
experimentation,  but  its  uses  at  the  bedside  are  few.  Clinicians  are 
using  it  less  and  less  in  this  country.  It  should  not  be  relied  upon 
for  differential  diagnoses  in  valvular  diseases. 

In  endocarditis  there  are,  not  infrequently,  attacks  of  tumultu- 
ous action,  with  distressing  palpitation,  the  impact  extending 
over  a  considerable  area.  In  the  intervals  between  these  attacks, 
the  action  of  the  heart  may  be  quite  regular,  the  apex  beat  inap- 
preciable to  the  finger,  and  a  "thrill,"  which  was  distinctly  felt, 
■may  disappear. 

Auscultation  yields  the  most  important  information.  Suppos- 
ing a  valve,  say  the  mitral,  is  obstructed  to  a  considerable  extent, 
so  that  it  cannot  close  perfectly,  the  blood  will  necessarily  leak 
Iback  into  the  left  auricle,  during  the  contraction  of  the  left  ventri- 
'cle.  In  such  case  the  first  sound,  which  is  due  chiefly  to  the 
closure  of  the  mitral  valve  and  to  muscular  action,  is  replaced  by 
a  murmur  caused  by  the  leaking  or  regurgitant  blood  passing 
through  the  obstructed  opening,  and  this  sound  is  best  heard 
between  the  apex  and  the  axilla  or  spine  of  the  scapula,  where 
it  is  conveyed,  in  accordance  with  the  rule's  governing  the 
conduction  of  sound.  If  the  new  deposits  in  the  valve 
are  soft  and  smooth,  the  murmur  is  soft ;  if  very  rough  or  irregular, 
it  is  loud  or  harsh.  This  is  provided  the  heart's  action  is  strong; 
if  it  is  weak,  there  may  be  no  appreciable  murmur.  Sometimes 
a  harsh  murmur  suddenly  disappears,  while  the  action  of  the  heart 
continues  the  same.  Some  portion  of  the  obstruction  has  then  been 
swept  away.  There  are  not  the  hard  and  fast  areas  in  which  to 
hear  the  several  murmurs,  as  laid  down  in  some  books,  and  there  is 
quite  a  little  dift"erence  of  opinion  as  to  the  locality  of  these  areas 
among  teachers  of  physical  diagnosis.  The  truth  is  that  the  point 
of  maximum  intensity  for  determining  mitral  regurgitation  is  be- 
tween the  apex  and  the  axilla  or  scapula ;  but  in  mitral  stenosis  the 
point  of  maximum  intensity  extends  from  the  apex  upwards  and 
downwards  perhaps  as  much  as  an  inch  or  more,  and  a  less  distance 


^S  Endo-Cardiopathies 

to  the  right.  In  aortic  obstruction  tlic  obstructive  unirniur  is  beard'. 
best  over  the  right  3d  costo-sternal  junction,  or  at  the  junction  of 
the  second  right  interspace  \vith  the  sternum,  or  even  as  far 
over  as  the  correspon(Hng  space  on  tlie  left  side;  while  the  aortic 
regurgitant  may  be  well  heard  along  a  broad  area  spreading  like 
a  fan  from  the  aortic  area  to  the  ai)ex,  or  even  to  the  cnsiform 
appendix.  As  the  point  of  maximum  intensity  for  the  tricuspid  is 
located  at  the  junction  of  the  left  fifth  interspace  with  the  sternum,, 
it  is  not  far  from  the  mitral  area,  ami  its  munuurs  may  be  conveyed 
to  that  area  :  hence  it  may  be  difficult  to  make  a  diagnosis  between 
these  two  lesions,  rulmonar}  lesions  are  so  rare  that  they  are  curi- 
osities ;  most  of  them  are  due  to  congenital  malformations  of  the 
heart.  In  general,  the  murmurs  indicative  of  the  greatest  danger 
are  the  diastolic. 

Percussion  is  at  first  negative,  but,  as  endocarditis  progresses, 
the  contour  of  the  heart  gets  larger  and  more  ovoid.  This  enlarge- 
ment is  the  most  important  sign  of  organic  heart  disease,  because 
it  is  unequivocal. 

The  heart  swings  like  a  pendulum  in  the  cavity  of  the  chest,  sus- 
pended by  its  great  vessels ;  so  that  the  apex  is  carried  well  outside 
the  nipple  in  some  cases,  especially  in  lateral  curvature,  where  the 
spinal  concavity  is  generally  to  the  left.  It  may  also  be  displaced" 
to  the  right  by  fluid  in  the  chest,  and  by  lying  on  the  right  side.  Still, 
as  we  only  examine  in  the  upright  or  recumbent  positions,  it 
is  relatively  fixed,  and  we  find  the  apex  in  the  fifth  space,  the  left 
border  of  the  heart  the  breadth  of  a  rib  inside  the  nipjile,  and  about 
twice  that  distance  below  it.  The  right  auricle  is  al)0ut  the  only 
part  of  the  heart  outside  the  right  border  of  the  sternum.  Two- 
fifths  of  the  heart  lies  to  the  left  of  the  median  line. 

-Ingina  pectoris  is  not  uncommon  in  endo-cardio]:)athies.  Both 
forms,  which  are  best  classified  as  the  mild  and  the  severe,  are  usu- 
ally brought  on  by  mental  or  moral  excitement,  indigestion,  over- 
exertion, and  a  number  of  minor  causes,  especially  those  that  in- 
fluence the  special  senses.  They  are  always,  in  my  experience,  capable 
of  being  controlled  by  suitable  remedies,  though  drugs  may  prove 
ineffectual  when  rest,  massage,  electricity,  baths  or  a  change  of  scene 
will  succeed. 

Endocarditis  gives  rise  to  various  symptoms  in  other  organs, 
for  there  may  be  hypersemia  of  the  lungs,  embarrassed  respiration, 
engorgement  of  the  kidney  and  chylopoetic  tract,  and  even  general' 
dropsy. 


Endo-Cardiopathies  39 

•^  A  distinct  picture  is  produced  iu  these  cases  l)y  embolism,  where 
,;articles  detached  from  the  diseased  endocardium,  or  clots  formed 
about  the  valves,  in  the  auricular  appendages,  or  about  the  papillary 
muscles,  arc  carried  to  distant  organs.  These  accidents  may  cause 
few  symptoms,  and  yet  may  involve  the  brain,  causing  alarming  re- 
sults, and  even  sudden  death.  But  if  the  collateral  circulation  is  rap- 
idly established,  little  or  no  functional  disturbance  will  be  produced. 
As  terminal  arteries,  however,  are  found  in  the  brain,  lungs,  spleen, 
kidneys  and  heart,  the  occlusion  of  large  vessels  in  these  organs  is  apt 
to  be  followed  by  severe  symptoms,  such  as  chills,  vomiting,  pain  and 
haemorrhage.  Benign  emboli  may  cause  only  arrest  of  function,  but 
the  malignant  or  septic  will  certainly  produce  abscesses  that  in  turn 
will  furnish  foci  for  others.  Embolism  of  tlie  brain  occurs  most 
frequently  along  the  line  of  the  branches  of  the  left  carotid,  the 
trunk  of  which  lies  directly  in  the  course  of  the  circulation.  The 
embolic  masses  find  their  way  through  this  carotid  to  a  branch  of 
the  Sylvian  artery,  and  if  there  is  occlusion  of  a  large  branch,  loss  of 
consciousness,  hemiplegia  and  aphasia  usually  follow. 

In  young  or  middle  life,  embolism  is  the  rule ;  in  advanced  life, 
apoplexy.  Embolism  of  the  lungs  has  characteristic  features.  If 
a  vessel  of  any  considerable  size  gets  plugged  there  is  apt  to  be  pain, 
vomiting,  cough,  dyspnoea,  haemorrhage,  and  expectoration  of 
frothy  mucus;  perhaps  cyanosis,  suffocation  and  syncope.  Etnbol- 
i.wi  of  the  liver  may  be  ushered  in  with  chills,  pain,  swelling,  tender- 
ness and  icterus.  Embolism  of  the  spleen  also  shows  itself  with 
a  chill,  fever,  and  severe  pain  in  the  organ,  which  should  be  en- 
larged and  tender  to  the  touch.  Embolism,  of  the  kidneys  similarly 
may  be  ushered  in  by  chills,  fever,  pain  and  albuminous,  perhaps 
bloody  urine.  Embolism  of  the  mesenteric  arteries  is  revealed  by 
colicky  pain  in  the  abdomen,  diarrhoea  and  discharges  of  black  blood. 
Embolism  of  the  retina  is  sometimes  seen  with  the  ophthalmoscope. 
If  septic,  it  causes  inflammation  and  destruction  of  the  globe.  Em- 
bolism of  the  skin  may  cause  purpura  or  gangrene. 

In  fact,  embolism  arrests  the  function  of  the  part  where  the  in- 
farct is  lodged,  and  if  septic,  produces  destruction  of  tissue. 

So  long  as  compensation  is  imperfect,  there  are  also  other  com- 
plications. For  whenever  the  heart  begins  to  labor,  congestion  of 
the  veins  and  capillaries  of  the  lungs  immediately  results,  and  then 
the  bronchial  mucous  membrane,  alveoli  and  passages  become 
swollen  and  oedematous  ;  with  eventual  desquamation  of  epithelium, 
and  transudation  of  mucus,  serum  and  blood.      Embarrassment  of 


40  Endo-Cardiopathies 

respiration  ensues,  and  it  is  heightened  b)  the  increased  efforts  of 
the  lungs  to  aerate  the  abnormal  quantity  of  blood  in  the  pulmonary 
vessels.  Such  a  condition  may  be  only  temporary,  constituting 
pulmonary  oedema ;  but  if  it  become  chronic,  the  character  of  the 
lung  tissue  is  changed,  for  the  continued  venous  engorgement  is 
followed  by  deposits  of  pigment  matter.  This  leads  to  what  is 
known  as  brou'n  induration  of  the  lungs,  and  even  rupture  of  pul- 
monary vessels ;  indeed,  pulmonary  hccmorrhage  is  not  uncommon  in 
chronic  heart  diseases. 

The  liver  also  becomes  enlarged  from  a  similar  cause,  and  pig- 
mented. In  fact,  there  is  a  congestion  of  the  entire  chylopoetic  sys- 
tem, which  continues  so  long  as  the  heart  is  embarrassed.  As  soon 
as  there  is  congestion  of  the  venous  system,  it  is  shown  by  a  bluish 
color  of  the  skin  or  visible  mucous  membranes. 

Thrombosis  may  also  occur,  and  cases  have  been  described  by 
Welch,  A.  A.  Smith,  and  MacGregor.  (See  Amer.  Medicine,  May 
25,  1901,  and  Brannan,  Med.  Rec.,  Feb.  22,  1902.) 

For  a  similar  reason  the  kidneys  become  swollen,  and  later  tough 
and  firm.  The  urine  is  diminished,  but  the  specific  gravity  is  in- 
creased ;  it  may  contain  blood,  and  usually  a  little  albumin ;  some- 
times a  little  sugar,  varying  from  ^  to  23^  per  cent.  Oedema,  due 
to  prolonged  distention  of  the  veins  of  the  peripheral  system,  he- 
patic or  renal  implication,  deserves  attentive  consideration.  But 
all  cases  of  oedema  about  the  ankles,  hands  or  face  need  not  alarm 
us.  They  may  occur  from  lack  of  exercise  or  anaemia,  or  temporary 
compensatory  failure,  and  will  disappear  under  appropriate  treat- 
ment. Accumulations  of  fluid,  however,  in  the  abdominal  cavity,  or 
oedema  ascending  gradually  from  the  ankles  to  the  trunk,  are  very 
serious  matters,  pointing  to  a  fatal  issue  at  an  early  date. 

If  the  valvular  disease  is  at  all  serious,  dilatation  and  hypertro- 
phy of  the  right  or  left  ventricle  will  supervene.  Hypertrophy  is 
essentially  a  compensatory  change,  enabling  the  heart  to  do  the  work 
required  of  it,  notwithstanding  the  valvular  disease,  and  to  re-estab- 
lish the  proper  balance  between  the  arterial  and  venous  systems. 

In  aortic  disease  compensation  produces  the  long  heart,  due  to 
dilatation  and  hypertrophy  of  the  left  ventricle.  On  the  other  hand, 
in  pulmonary  stenosis,  which  is  rare,  of  course,  the  right  ventricle 
dilates  and  hypertrophies.  As  soon  as  the  former  cardiac  balance 
has  been  restored  by  the  means  just  described,  we  say  that  com- 
pensation has  been  established,  for  then  the  consequences  of  the 
valvular  disease  have  been  overcom.e,  for  the  time  at  least.     While, 


Endo-Cardiopathies  41 

however,  compensation  is  being  established  the  patient  is  short- 
winded,  cannot  walk  any  distance,  has  precordial  pain  owing  to  the 
dilatation,  perhaps  fainting  fits,  and  feels  physically  exhausted  at  the 
end  of  the  day.  But  after  compensation  has  been  established  all 
these  symptoms  disappear,  and  he  feels  as  well  as  most  persons, 
except  if  called  on  for  some  extra  exertion,  or  upset  by  some  emo- 
tional disturbance.  Enlargement  of  the  liver  helps  to  detect  lack 
of  compensation.  It  indicates  dilatation  of  the  right  ventricle  and 
right  auricle  as  well.  If  there  is  obstruction  in  the  pulmonary  cir- 
culation, the  right  auricle  is  pretty  certain  to  be  dilated. 

But  it  is  a  mistake  to  think  that  compensation  calls  only  for 
dilatation  and  hypertrophy  of  particular  chambers  of  the  heart, 
corresponding  to  certain  valves.  If  the  valvular  lesions  are  at  all 
serious,  both  ventricles  and  both  auricles  are  eventually  more  or 
less  dilated  and  hypertrophied,  owing  to  the  close  relation  they  hold 
to  each  other. 


Chapter  III. 

'\CI;TK    ENDOCARDITIS:    BENIGN    AND    MALIGNANT.^ 

l-'or  convenience  sake  acute  endocarditis  may  be  said  to  have 
two  prominent  types,  the  benign  or  non-suppurative,  and  the  ma- 
lij^^nant  or  suppurative.  The  latter  variety  has  also  been  known  as 
the  mycotic,  infective,  etc.,  but  as  both  contain  micro-organisms 
in  the  endocardial  dei)Osits,  and  are  associated  with  systemic  in- 
fections, these  terms  are  inappropriate.  Nor  has  the  word  ulcera- 
tive, as  a])plied  to  endocarditis,  an\  distinct  value,  because  all  forms 
tend  to  ])roduce  ulceration. 

The  acute  benign  form  is  by  far  the  most  frequent.  In  an  analy- 
sis of  forty-eight  cases  of  endocarditis,  verified  by  post-mortems, 
some  years  ago-  I  found  that  it  was  rarely  produced  by  an  injury, 
but  more  often  resulted  from  systemic  poisoning,  such  as  rheumatism, 
scarlatina,  measles,  etc.,  though  in  about  half  my  cases  I  did  not 
discover  the  cause.  In  the  light  of  our  present  knowledge,  how- 
ever, we  may  attribute  it  also  to  a  large  number  of  minor  ailments, 
mcluding  gastro-intestinal  alTcctions,  tonsillitis,  etc.,  which  are  now 
known  to  immediately  precede  the  attack.  I  saw  such  an  instance 
in  1901  at  the  New^  York  Orthopedic  Hospital,  with  Dr.  Hibbs,  in 
an  otherwise  healthy  boy  of  seven,  who  entered  the  hospital  to  be 
operated  on  for  congenital  dislocation  of  the  hip.  After  the  opera- 
tion, from  which  there  was  at  first  no  unfavorable  reaction,  he  devel- 
oped an  obstinate  diarrhoea,  in  the  course  of  which  there  was  a  sharp 
attack  of  endocarditis.  In  this  case  the  gastro-intestinal  tract  appears 
to  have  been  the  source  of  the  infection.  I  am  inclined 
to  think  that  various  systemic  poisons,  many  of  them  still  unknown 
to  us,  produce  the  disease.  But  it  is  an  incident  of  systemic  affec- 
tions, rather  than  a  separate  entity.  In  most  cases  endocarditis 
selects  those  portions  of  the  endocardium  which  are  at  or  about  the 
valves.  The  first  gross  evidences  of  disease  consist  in  the  formation 
of  minute  reddish  excrescences  near  the  free  valve  margins.  In 
ihe  mitral  leaflets  they  are  on  the  auricular  surfaces,  in  the  aortic 
leaflets  on  the  ventricular  surfaces. 

Soon   after   these    soft    excrescences    appear    they    are    covered 

'  Published  originally  in  the  Medical  Times.  Mav.  1901. 
'.V.  Y.  Medical  Record,  Feb.  27,  1886. 


Acute  Endocarditis  43, 

with  layers  of  fibrin,  hence  the  term  diphtheritic.  'J'wo  processes 
are  now  possible,  either  a  healing,  with  thickening-  and  puckering 
of  the  leaflets,  or  a  degeneration  that  leaves  broken  surfaces  or  ul- 
cers. And  yet,  when  this  degenerative  process  goes  on  there  is  about 
it  a  regenerative  process  by  which  Nature  attempts  to  heal  the  part 
and  restore  its  function.  At  all  times  micro-organisms,  in  greater 
01-  less  number,  are  found  in  the  fibrin  or  granular  debris  of  the  ulcer- 
ating surfaces.  The  degenerating  matter,  or  the  fibrin  attached  to 
it,  may  produce  infarcts  in  various  parts  of  the  body. 

In  extra-uterine  life  the  left  side  of  the  heart  is  most  frequently 
attacked;  in  congenital  disease  the  right. 

Patients  seldom  suffer  much  from  the  simpler  forms  of  endo- 
carditis in  their  early  stages.  They  often  complain  of  some  prae- 
cordial  pain,  though  symptoms  such  as  this  may  be  due  to  an  asso- 
ciated pericarditis,  the  irregular  action  of  a  hypertrophied  heart,  or 
pulmonary  complications.  In  a  large  number  of  cases  there  is  a 
noteworthy  frequency  of  the  pulse  (a  rate  of  120  to  140  is  not  un- 
common at  first).  Dyspnoea,  orthopnoea  and  palpitation  also  are  of 
pretty  regular  occurrence.  But  it  is  the  accidents  and  complica- 
tions that  are  most  dangerous  to  life.  In  a  disease  which  in  nine 
out  of  ten  cases  lasts  for  years  (sometimes  twenty  and  thirty,  and 
even  more)  it  is  natural  that  these  accidents  should  at  times  occur ; 
and  we  find  them  in  the  shape  of  infarcts  in  the  kidneys,  lungs,, 
spleen  or  brain,  etc.,  in  one-third  of  the  patients. 

The  danger  therefore  increases  as  the  disease  becomes  chronic. 
For  in  the  great  majority  of  cases  patients  survive  the  acute  stage,, 
though  embolism  may  occur,  even  at  that  time,  as  we  have  seen. 

Often  the  acute  or  benign  form  eludes  observation.  However,, 
we  should  be  on  the  lookout  for  it  in  acute  rheumatism,  especially 
when  the  temperature  rises  to  100°  or  102°  F. ;  and  also  in  pneu- 
monia and  scarlet  fever.  It  is  less  frequent  in  typhoid,  erysipelas^ 
bronchitis  and  gastro-intestinal  afifections. 

The  diagnosis  is  beset  with  some  difficulties,  or  otherwise  it 
would  be  recognized  more  frequently.  The  signs  include  palpi- 
tation, dyspnoea,  prascordial  pain,  insomnia,  often  rapid  and  irreg- 
ular pulse,  headache,  and  anxiety.  In  the  first  attack  there  may  be  no 
enlargement  of  the  heart,  and  therefore  no  dislocation  of  the  apex. 
In  adults  we  have  to  deal  most  often  with  acute  exacerbations  of 
a  chronic  malady,  or  the  recrudescence  of  a  latent  endocarditis.  In 
the  majority  of  cases  the  disease  is  either  in  the  mitral  or  aortic  valve. 
One  of  the  main   difficulties   encountered,   however,   in  making   a 


44  Acute  Endocarditis 

diagnosis,  is  that  the  acute  attack  is  apt  to  be  engrafted  on  a 
chronic,  or  at  least  a  latent,  condition  ;  or.  the  lesion  may  be  masked 
by  a  pericarditis. 

In  acute  endocarditis  the  tirst  requisite  is  rest  in  bed.  As 
far  as  possible  we  should  avoid  drugging ;  and  stimula- 
tion by  alcoholics  may  also  be  harmful.  But  the  diet  should  be  care- 
fully regulated.  Starchy  and  saccharine  substances  should  be  pro- 
hibited. For  children,  milk  is  the  best  food,  and  it  is  also  good  for 
adults,  if  it  agrees  with  them."  It  may  be  diluted  with  one-third 
to  one-half  lime-water  in  children ;  with  Seltzer  and  Vichy  in 
adults.  The  patient  should  also  be  kept  in  a  quiet  room  and  free 
from  all  annoyances.  As  soon  as  practicable,  efforts  should  be 
made  to  combat  the  systemic  disorder.  If  it  is  rheumatism,  the 
salicylates  should  be  given  with  caution,  in  5  to  10  grain  doses^ 
every  two  to  four  hours,  with  an  alcoholic  or  diffusible 
stimulant ;  but  not  in  sufficient  quantity  to  produce  vertigo, 
ringing  in  the  ears,  or  constitutional  symptoms.  A  little  pal- 
pitation may  be  let  alone.  If,  however,  the  heart  acts  tumultu- 
ously,  a  cold  compress  may  be  put  to  the  prgecordial  region,  and  bro- 
mides, such  as  the  bromide  of  sodium  or  monobromate  of  camphor, 
giv^en.  The  latter  is  an  excellent  remedy,  in  2  grain  doses.  Two 
or  three  grains  of  Dover's  powder  every  two  hours  is  also  excellent. 
Aconite,  in  i  minim  doses  every  two  hours,  is  soothing  if  there  is 
fever.  Phenacetine  may  also  be  given  to  adults,  in  3  to  5  grain  doses, 
with  a  stimulant  at  bedtime,  if  the  effects  of  the  drug  can  be  watched. 
Digitalis  should  not  be  given,  or,  if  at  all,  with  great  caution.  It 
is  a  dangerous  remedy  in  these  cases.  In  intense  arrhythmia  stro- 
phanthus  may,  however,  be  tried  cautiously,  because  it  is  soothing ; 
but  it  is  apt  to  be  unreliable  and,  like  digitalis,  it  should  be  given 
in  emergencies  only,  and  for  a  very  short  time.  The  milder  reme- 
dies should  be  tried  first. 

The  following  two  cases  illustrate  the  benign  type. 

Case  I.  Acute  Benign  Aortic  Endocarditis  Engrafted  on  the 
Chronic  Form. — E.  B.,  twenty-two,  colored,  was  admitted  to  hospi- 
tal December  11,  1880.  Three  weeks  previously  he  had  been  taken 
with  prrecordial  distress,  palpitation  and  dyspnoea,  slight  cough  with 
white  sputum,  orthopnoea ;  at  times  nausea  and  vomiting. 

On  physical  examination  the  heart  was  '  found  hypertrophied, 
with  apex  to  left  of  nipple.  Wavy  movement  of  the  epigas- 
trium. Expiration  prolonged,  and  high-pitched  behind.  Murmur 
at  apex  with  first  sound.     Pulsation  of  jugulars.      The  murmur, 


Acute  Endocarditis  ^5 

supposed  to  be  mitral  regurgitant,  was  carried  to  the  left,  but  was 
better  heard  above  the  scapula  than  below  it.  The  patient  died  of 
pneumonia.  At  the  autopsy  an  abnormal  amount  of  fluid  was 
found  in  the  pericardium,  and  some  in  the  pleural  cavities.  Both 
hmgs  were  solidified  at  their  bases,  and  pigmented.  Nutmeg  liver. 
Kidneys  and  spleen  congested.  The  heart  was  hypertrophied.  Pul- 
monary opening  dilated.  Right  heart  dilated.  Mitral  valve  nor- 
mal, but  aortic  valve  the  seat  of  fresh  vegetations,  and  posterior 
cusps  thickened  and  inflamed. 

This  case  was  an  acute  benign  aortic  endocarditis  with  hyper- 
trophied heart.  The  murmur  at  the  apex,  supposed  to  occur  with 
the  first  sound,  heard  best  behind  and  above  the  scapula,  proved  to 
be 'One  of  those  instances  where  the  murmur  of  aortic  regurgitation 
is  conveyed  to  the  apex  from  the  aortic.  And  it  opens  the  question 
w'hether  the  regurgitant  murmur  was  conveyed  to  the  apex  by  the 
sternum,  the  solidified  lung  or  the  heart  walls.  It  also  illustrates 
the  importance  in  these  doubtful  cases  of  noting  that  in  the  aortic 
regurgitant  the  murmur  may  be  conveyed  above  the  scapula ;  and 
farther,  that  the  second  sound  may  be  mistaken  for  the  first.  The 
pulmonary,  though  dilated,  appears  to  have  been  sufficient. 

Case  II.  Acute  Benign  Mitral  Obstruction;  Pericarditis. — 
C.  W.,  twenty-one,  single,  was  admitted  to  hospital  January  25, 
1884.  He  believed  himself  in  good  health  up  to  five  weeks  before 
admission,  when  he  had  an  attack  of  acute  articular  rheumatism. 

On  physical  examination  a  systolic  murmur  was  heard  at  the 
apex.  Liver  enlarged ;  albumin  and  casts  in  the  urine ;  oedema  of 
legs.  These  symptoms  improved,  but  at  the  end  of  four  weeks 
there  was  an  increased  oedema,  which  reached  to  his  scrotum.  About 
this  time  a  "purring  thrill"  was  noticed  at  the  apex  and  a  double 
murmur  at  both  apex  and  base.  The  patient  died  a  few  days  later, 
in  coma.  At  the  autopsy  the  pericardial  sac  was  found  to  contain 
a  large  amount  of  serous  fluid,  with  fibrin  in  flakes.  Both  visceral 
and  parietal  layers  of  the  pericardium  were  covered  with  a  fibro- 
plastic material.  On  the  mitral  valves  were  villous  granulations 
sufficient  to  produce  obstruction.  The  other  valves  were  normal. 
I.Amgs  congested  and  oedematous. 

This  case  illustrates  how  an  associated  pericarditis  mav  obscure 
an  endocarditis.  The  "purring  thrill,"  however,  pointed  to  mitral  ob- 
struction. 

Septic  or  suppurative  endocarditis  is  a  comparatively  rare  dis- 
ease.    In  a  series  of  forty-eight  cases  of  endocarditis  I  found  it  in 


46  Acute  Endocarditis 

only  three,  or  about  6  per  cent.  And  from  a  review  of  others  of 
my  cases  to  date,  I  think  it  is  even  less  common  than  these  figures 
would  imply.  In  fact,  it  is  an  unusual  form  of  purulent  infection. 
The  lesions  in  the  valves  ma}-  be  vegetative  or  ulcerative,  but  always 
suppurative ;  "so  that  the  emboli  are  necessarily  sei)tic.  eventually 
producing  metastatic  abscesses. 

So  rare  is  the  disease  that  it  often  escapes  notice,  but  there  are 
certain  signs  which  should  attract  our  attention.  They  are  those 
of  anaemia,  embolism  and  metastatic  abscesses,  in  conjunction  with 
theother  subjective  or  objective  phenomenaofendocarditisandsepsis. 

If.  in  a  case  of  pueri)eral  fever,  pneumonia,  suppuration  from 
bones  or  joints,  gonorrhoea,  or  any  form  of  infection,  or  in  trauma- 
tism, signs  of  endocarditis  develop,  we  should  suspect  the  septic 
or  suppurative  form,  especially  if  there  are  chills  and  fever  (even 
though  periodic)  with  an  enlarged  and  tender  spleen,  and  bloody 
tirine. 

In  suspected  malignant  endocarditis  the  blood  should  always 
be  examined.  Sometimes  a  pyogenic  coccus  can  be  cultivated,  indi- 
cating that  there  is  a  septicaemia ;  or  the  gonococcocus  may  point 
to  the  cause  of  the  disease,  just  as  the  pneumococcus  suggests  the 
lung,  and  the  colon  bacillus  the  intestines  as  the  gates  of  infec- 
tion. Usually  with  the  anaemia  there  is  marked  leuocytosis,  to- 
gether with  destruction  of  red  blood  cells,  which  may  be  reduced  to 
J, 000,000.      (Ewing.) 

If  blood  examinations  in  a  suspected  case  fail  to  react  for  ty- 
phoid, malaria  or  tuberculosis,  a  diagnosis  of  malignant  endocardi- 
tis may  be  made  by  exclusion.     (Cabot.) 

In  a  case  of  gonorrhoeal  endocarditis,  however,  reported  by  Stein 
{Wien.  Klin.  IVoch.,  Nov.  22,  1900),  Weichselbaum  found  strej!)- 
tococci,  the  inference  being  that  the  gonococci  simply  made  the  soil 
favorable  for  other  bacteria,  and  that  the  case  was  one  of  mixed 
infection.  I  am  inclined  to  think  that  there  are  several  micro- 
organisms concerned  in  the  production  of  this  acute  infection.      >• 

The  diagnosis  is  manifestlyy  difficult,  and  yet  is  not  impossibfe, 
if  all  the  phenomena  are  taken  into  consideration.  The  signs  in- 
clude precordial  pain,  dyspnoea,  headache,  insomnia,  irregular  chills, 
sweats  and  fever,  anxiety,  rapid  and  irregular  pulse,  and  the  phys- 
ical signs  of  endocarditis,  with  septic  or  pygemic  manifestations ;  in 
short,  the  signs  of  endocarditis,  with  a  tendency  to  metastatic  ab- 
scesses. Inasmuch,  however,  as  in  most  cases  the  acute  form  of  the 
disease  is  engrafted  on  an  old  one,  we  should  also  inquire  as  to 


Acute  Endocarditis  47 

whether  there  have  been  previous  signs  of  endocarditis.  Therefore, 
we  should  expect  to  find  some  dilatation  of  the  heart,  with  a  dislo- 
cation of  the  apex  outwards  or  downwards,  or  both.  The  organic 
murmurs  of  septic  endocarditis  are,  so  far  as  my  experience  goes, 
confined  to  the  aortic  and  mitral  valves. 

The  disease  is  usually  fatal  in  a  few  days,  but  cases  have  been 
reported  where  it  has  lasted  for  months.  Recoveries  must  be  very 
rare.  In  my  opinion  most  of  the  cures  reported  have  been  in  cases 
where  there  has  been  embolism,  with  chills  and  sweats,  but  the  em- 
boli have  been  benign.  Personally  I  have  never  known  a  case  of 
recovery  in  malignant  endocarditis.  1  have,  however,  known  re- 
covery to  follow  gonorrhoeal  rheumatism  with  metastatic  deposits, 
and  I  have  also  seen  one  recovery  in  pure  pyaemia.  Septic  endo- 
carditis should  not,  therefore,  be  altogether  hopeless. 

The  following  are  illustrative  cases : 

Case  III.  Acute  Malignant  Endocarditis;  Caries  of  the  Carpal 
Bones. — A.  C,  colored,  aged  forty-six ;  was  admitted  to  hospital 
November  5,  1878.  He  was  first  taken  sick  on  October  25th,  but 
had  never  before  been  seriously  ill.  At  first  he  had  pain  in  the  left 
knee,  and  about  the  same  time  there  were  chilly  sensations,  followed 
by  headache,  fever  and  backache.  He  took  to  his  bed,  and  remained 
there  until  removed  to  hospital.  On  admission,  there  was  found  to 
be  pain  on  the  left  side  (spleen?),  and  in  his  left  leg.  His  wrist 
also  was  swollen,  tender  and  intensely  painful.  No  fever,  but  great 
prostration.  On  November  28th,  after  showing  no  signs  of 
improvement,  he  passed  blood  per  rectum.  Probably  there 
had  been  an  evening  rise  of  temperature  for  some  time.  It  re- 
mained between  101°  and  102°  until  December  3d.  Towards  the 
last  it  rose  to  104°.  pulse  to  116  and  respiration  to  46.  At  the  post- 
mortem examination  no  cardiac  hypertrophy  was  observed,  but  at 
the  aortic  orifice,  beneath  one  of  the  cusps,  w^as  a  verrucose  growth 
the  size  of  a  small  chestnut,  while  the  valve  was  ruptured.  On  remov- 
ing the  brain,  pus  was  found  in  the  meshes  of  the  pia  mater.  At 
the  wrist  (left?)  the  first  row  of  carpal  bones  was  found  necrotic 
or  carious.  Duration  of  the  disease,  six  wrecks.  In  this  case  the 
evidence  pointed  to  necrosis,  or  caries,  of  the  carpal  bones  as  the 
source  of  the  acute  endocarditis,  though  the  evidence  connecting  it 
is  not  as  satisfactory  as  one  might  wish,  because  at  the  time  no 
special  attention  was  directed  to  the  endocarditis. 

Case  IV.  Lobar  Pneumonia;  Malignant  Endocarditis. — The 
history    of    this    case    was    sent    me     from    St.     Francis    Hos- 


48  Acute  Endocarditis 

pital.  A  patient  of  alcoholic  habits,  aged  forty-one,  was  ad- 
mitted in  November  of  1882^  with  a  lobar  pneumonia.  There 
was  high  temperature,  but  no  cardiac  murmurs  were  detected. 
Other  and  apparently  more  important  conditions  obscured  the  car- 
diac disease.  At  post-mortem  examination  the  aortic  cusps  were 
found  extensively  diseased,  each  segment  exhibiting  vegetations, 
while  one  carried  a  growth  the  size  of  a  hickory-nut,  and  was  rup- 
tured and  ulcerated.  An  abscess  was  also  found  in  the  course  of 
the  coronary  artery,  and  a  sinus  led  from  it  to  the  fungating  mass 
in  the  aortic  valve."  The  spleen  contained  an  infarct.  Duration  of 
the  illness,  about  five  weeks.  The  malignant  endocarditis  was 
probably  closely  related  in  etiology  to  the  pneumonia. 

Case  V.  Malignant  Endocarditis;  Sufypurativc  hifarcts. — A 
gentleman  of  this  city  was  taken  sick  with  an  attack  of  fever  that 
confined  him  to  his  room  for  four  or  five  days.  He  then  felt  bet- 
ter and  went  downstairs,  but  soon  returned  and  took  to  his  bed. 
JDuring  the  first  two  weeks  of  his  illness  the  temperature  ranged 
from  98°  to  100°  F.,  his  pulse  from  140  to  150,  sometimes  reach- 
ing 160.  During  the  last  two  weeks  of  his  life  it  had  a  wider  range 
(120  to  150).  At  an  early  period  the  diagnosis  of  obstructive  en- 
docarditis was  made  out.  The  respiration  was  never  embarrassed, 
except  when  the  patient  sat  up.  There  was  never  any  impairment 
of  motion  or  sensibility,  nor  did  he  experience  any  pain,  except 
on  one  occasion  when  his  physician  attempted  to  turn  him  over 
on  his  left  side.  He  then  cried  out  suddenly,  "You  have  killed  me," 
and  placed  his  hand  over  the  region  of  the  spleen,  groaning  with 
pain.  He  recovered  from  this  attack,  but  died  subsequently  with 
suppression  of  urine. 

The  post-mortem  examination  revealed  a  stenosis  of  the  aortic, 
which  would  hardly  admit  the  passage  of  the  first  joint  of  my  little 
finger.  The  surfaces  of  the  cusps  were  marked  by  calcareous  con- 
cretions and  vegetations.  The  heart,  and  especially  the  left  ventri- 
cle, was  dilated  and  hypertrophied.  The  kidneys  presented  the  usual 
appearances  seen  in  the  large  variety  of  chronic  diffuse  nephritis, 
and  also  contained  both  recent  and  old  infarcts.  The  lungs  also  had 
infarcts.  The  spleen  and  the  meninges,  however,  showed  the  most 
important  lesions.  The  first-mentioned  organ  measured  about  nine 
inches  in  length,  and  was  the  seat  of  numerous  infarcts  of  various 
ages,  some  red,  others  brown  and  others  yellow,  while  one  had 
been  the  point  of  origin  for  an  abscess  from  which  a  pint  to  a  pint 
and  a  half  of  dirty,  grumous,  oflFensive  matter  was  discharged. 


Acute  Endocarditis  49 

Emboli  were  also  found  in  the  meshes  of  the  pia,  with  attendant 
suppuration.  This  acute  attack  was  plainly  engrafted  on  an  old 
rheumatic  endocarditis,  but  why  the  emboli  were  suppurative  was 
not  determined. 


Chapter  IV. 

MITRAL  INSUFFICIENCY.^ 

Mitral  insufticiency,  regurgitation  or  incompetency  is  a  com- 
paratively common  valvular  affection,  and  the  least  serious  of  any, 
so  long  as  it  is  uncomplicated.  But  it  is  seldom  the  only  valvular 
lesion.  From  my  tables  it  appears  that  in  86  per  cent,  it  was  asso- 
ciated with  aortic,  pulmonary  or  tricuspid  disease,  the  combination 
with  aortic  being  the  most  common.  The  most  frequent  cause  of 
insufficiency  is  endocarditis,  which  is  also  most  frequently  caused 
by  litha^mia.  Under  the  influence  of  this  and  other  constitutional 
vices  vegetations  form  along  the  borders  of  the  leaflets,  which 
thicken  and  then  retract,  wdiile  the  tendinous  cords  and  papillary 
muscles  also  become  infiltrated  and,  contracting,  hold  the  leaflets 
back.  Another  cause  of  inorganic  insufificiency  is  the  rupture  of  a 
leaflet.  All  of  these  phenomena  I  have  seen.  Finally,  the  orifice 
ma}'  be  involved  in  a  new  growth,  or  atheroma  may  prevent  closure. 
Usually,  however,  the  latter  infiltrates  a  leaflet  without  interfering 
with  its  closure. 

Of  the  inorganic  or  relative  form  there  are  many  varieties,  and 
it  may  be  a  temporar}-  or  permanent  condition.  One  of  the  most 
common  causes  is  violent  physical  exercise,  such  as  young  men  are 
subjected  to,  in  training  for  athletic  sports.  In  one  of  the  physical 
culture  schools  of  this  city  I  have  been  told  by  the  manager,  who  is 
also  a  physician,  that  most  of  the  prominent  athletes  under  his 
tuition  are  affected  wath  mitral  regurgitant  murmurs  during  their 
training.  Or  an  aneurysm  of  the  arcli  causing  the  large  heart  so 
common  in  aortic  disease  is  pretty  apt  to  entail  some  relative,  that 
is.  inorganic,  dilatation ;  or  in  plainer  language,  stretching  of  the 
mitral  orifice.  This  is  because  the  whole  left  heart  must  dilate  and 
the  tendinous  cords  and  papillary  muscles  stretch  (the  leaflets  usu- 
ally failing  to  enlarge  in  size,  so  as  to  fit  the  enlarged  orifice).^ 

In  a  somewhat  similar  way  the  fatty  heart  may  dilate,  the  leaflets 
failing  to  enlarge  proportionately.  Now,  it  is  quite  apparent  that 
this  form  of  insufficiency  is  capable  of  remedy,  provided  the  condi- 
tion governing  it  is  removed. 


^  Published  originally  in  the  A''.  Y.  Med.  Journal,  Feb.  12.  1902. 
'  In  some  instances  the  valve  leaflets  do  actually  enlarge  to  compensate 
for  the  enlarged  valvular  openings. 


Mitral  Insufficiency  5^ 

Probably  it  is  quite  common  as  a  temporary  affair — for  example, 
after  a  set  at  tennis,  a  boat  race  or  a  running  match,  in  recovery 
from  fevers,  or  after  an  infection  or  in  cardiac  neuroses.  At  autop- 
sies we  are  not  likely  to  see  very  many  of  these  accidents,  because 
they  do  not  cause  death.  On  the  other  hand,  we  not  infrequently 
find  at  autopsies  an  artificial  mitral  insufficiency  where  post-mortem 
softening  has  set  in.  This  condition  is  less  often  seen  now  than 
formerly,  owing  to  the  system  of  post-mortem  refrigeration  that  is 
at  present  in  vogue. 

In  mitral  insufficiency  there  is  such  an  imperfect  closure  of  the 
mitral  leaflets  that,  during  systolic  contraction  of  the  left  ventricle, 
more  or  less  blood  leaks  back  into  the  left  auricle,  already  partly 
filled  with  blood  coming  from  the  lungs.  Necessarily  the  left  auri- 
cle dilates  and  then  hypertrophies,  because  it  has  more  blood  to 
be  driven  into  the  left  ventricle.  And  inasmuch  as  the  left  ventricle 
has  to  use  more  force  in  order  to  supply  the  aorta  with  its  proper 
quantum  of  blood,  it  also  hypertrophies  after  dilating.  But  over- 
filling of  the  left  auricle  dams  the  blood  back  on  the  lungs  and 
offers  such  resistance  to  the  column  coming  from  the  right  ventricle 
that  this  also  hypertrophies  and  gives  way,  causing  dilatation  of  the 
right  auricle,  whenever  the  tricuspid  yields. 

The  most  characteristic  sign  of  mitral  insufficiency  is  a  systolic 
murmur  between  the  apex  and  the  axilla  or  scapula,  due 
to  the  leakage  of  the  mitral  during  the  contraction  of  the  left  ventri- 
cle. This  murmur  will  vary  in  quality ;  it  is  usually  rough  and 
loud,  rarely  musical.  Inorganic  murmurs  are  softer  and  have  more 
of  a  blowing  character.  Regurgitant  murmurs  are  also  intensified 
by  slight  exertion. 

Accentuation  of  the  second  sound  over  the  pulmonary  artery  is 
another  sign  which  is  due  to  the  sudden  closure  of  the  pulmonary 
leaflets,  caused  by  the  strong  resistance  ahead  of  them  in  the  auricle. 

The  right  ventricle  gets  to  be  hypertrophied  rather  than  the 
left  when  compensation  is  accomplished,  so  that  we  look  for 
greatly  increased  transverse  dulness ;  for  the  left  border  of  the 
heart  may  extend  from  an  inch  or  two  to  the  right  of  the  sternum 
as  far  as  to  and  beyond  the  left  nipple. 

In  the  early  development  of  mitral  insufficiency,  of  the  organic 
form,  the  compensatory  symptoms  usually  go  hand  in  hand  with  the 
lesion,  so  that  although  a  systolic  murmur  is  present,  the  affection 
may  not  be  appreciated  by  the  patient  or  those  about  him.  Yet 
there  will  result  some  embarrassment  of  the  pulmonary  circulation, 


52  Mitral  Insufficiency 

^vhich  will  be  shown  by  a  little  shortness  of  breath  on  exertion,  per- 
haps by  an  increase  in  the  pulse  rate,  ^vith  more  or  less  irregularity. 

There  may  also  be  spitting  of  blood,  for  at  this  period  the  pul- 
monary vessels  are  all  dilated  and  cause  some  bronchorrhoea.  When 
compensation  is  fully  established  it  is  at  first  through  the  hyper- 
trophy of  the  left  ventricle,  but  eventually  and  chiefly  by  the  right, 
and  then  the  pulse  will  be  slow,  full  and  regular.  Compensation 
may  last  a  long  while,  with  patients  who  are  fortunate  enough  to 
combine  both  a  knowledge  of  their  condition  and  the  ability  to  con- 
trol adverse  incidents.  In  my  records  1  have  not  a  single  instance  of 
uncomplicated  mitral  insufficiency  in  which  death  w'as  attributable  to 
it ;  though  it  may  certainly  cause  death  when  complicated  with  some 
other  valvular  trouble. 

With  laboring  men  and  those  exposed  to  unusual  vicissitudes 
there  will  necessarily  be  lapses,  the  breakdown  at  the  end  coming 
earlier;  and  yet  during  all  this  time  the  systolic  murmur  may  con- 
tinue to  be  loud,  while  its  quality,  w^hether  rasping,  fiUng,  blowing, 
etc.,  or  even  musical,  will  depend  upon  the  physical  character  of  the 
orifice  and  adjacent  parts. 

In  my  opinion,  however,  organic  insufficiency  passes  over  even- 
tually into  stenosis  or  obstruction. 

Acute  relative  insufficiency  is  a  temporary  condition  that  will 
mend  with  rest  and  systemic  treatment ;  while  the  forms  that  re- 
sult from  muscular  weakness,  as  from  the  poison  of  diphtheria,  the 
continued  fevers  and  infections  generally,  from  faulty  innervation  or 
fatty  degeneration,  will  improve  synchronously  with  improvement  in 
the  conditions  producing  them. 

And  yet  in  the  mitral  insufficiency  of  day  laborers,  and  in  adher- 
ent pericardium,  there  is  less  likelihood  of  compensation,  because  the 
conditions  that  cause  it  are  apt  to  be  permanent.  In  uncomplicated 
cases  the  prognosis  is  good,  but  complications  are  to  be  expected. 

Ruptures  or  lapses  of  compensation  are  ushered  in  by  relaxa- 
tion of  the  ventricular  walls,  causing  venous  congestion,  first  of  the 
pulmonary  system  and  then  later  of  the  systemic.  At  the  end  the 
systolic  murmur  grows  faint  and  may  even  become  inaudible,  owing 
to  the  deficient  force  of  the  left  ventricle.  The  second  pulmonary 
sound  also  will  become  progressively  weaker,  owing  to  the  yielding 
of  the  right  ventricle. 

Venous  ptilsation,  or  certainly  a  wavy  motion  in  the  veins  of  the 
neck,  indicates  giving  way  of  the  right  ventricle.  The  surface  be- 
comes livid,  there  is  palpitation,  with  a  weak  and  intermittent  pulse. 


Mitral  Insufficiency  S3 

and  the  cardiac  impulse  grows  faint  or  disappears.  The  liver  may 
be  swollen  and  tender ;  the  urine  scanty  and  albuminous.  About 
this  time  dropsy  may  be  expected,  perhaps  delirium  cordis,  and  death 
is  a  natural  sequence.  Or  death  may  result  from  asystole,  though 
uraemia  or  pulmonary  haemorrhage  may  close  the  chapter. 

Up  to  the  period  of  breaking  compensation  the  three  cardinal 
signs  are:  i.  A  systolic  murmur  between  the  apex  and  the  axilla. 
2.  Accentuation  of  the  second  pulmonary  sound.  3.  Increased  trans- 
verse dulness  of  the  heart.  In  and  after  breaking  compensation  the 
diagnosis  must  be  based  on  the  previous  history,  because  the  ab- 
normal transverse  dulness  may  be  the  only  one  of  the  three  cardinal 
physical  signs  left  from  which  to  construct  a  diagnosis. 

If  obstruction  coexists,  as  it  does  in  from  70  to  80  per  cent, 
of  the  cases,  we  must  expect  a  systolic  thrill  at  or  near  the  apex  in 
from  15  to  60  per  cent.,  and  a  presystolic  murmur  in  at  least  from  lo 
to  30  per  cent.  In  children  or  young  people  there  may  be  a  bulging 
of  the  prsecordia. 

Mitral  insufficiency  is,  as  I  have  said,  comparatively  easy  to 
diagnosticate  in  uncomplicated  cases,  as  the  following  instance  will 
show: 

Case  VI.  Mitral  and  Tricuspid  Insufficiency. — L.  A.,  a  cabinet- 
maker, born  in  France,  seventy  years  old,  was  admitted  to  hospital 
January  3,  1881.  Eight  days  previously  he  was  taken  with  short- 
ness of  breath,  wheezing,  slight  cough  and  spitting  of  blood.  Soon 
his  legs  began  to  swell.  On  examination  fluid  was  found  in  the 
pleural  cavity.  Patient  cyanotic ;  heart  sounds  indistinct.  A  few 
days  later,  a  mitral  systolic  murmur  was  made  out,  wath  increased 
heart  dulness  and  diffuse  heart  beat.  A  cardiac  murmur,  loudest 
over  the  ensiform  cartilage,  was  attributed  to  tricuspid  regurgita- 
tion. Later  some  lung  consolidation  was  discovered.  At  the  post- 
mortem examination  the  aortic  and  pulmonary  valves  were  found 
normal,  while  the  right  cusp  of  the  mitral  was  thick  and  contracted 
and  bound  up.  Left  auricle  greatly  dilated.  Mitral  admitted  the 
tips  of  seven  fingers.  Valves  of  tricuspid  thickened  and  restricted 
in  movement ;  weight  of  heart,  23  ounces.  Both  lungs  contained 
red  infarcts.  Right  chest  full  of  serum  ;  left  chest  nearly  full.  This 
case  was  examined  by  several  of  our  best  clinicians,  the  result  being 
an  absolutely  correct  diagnosis  in  essential  particulars,  the  chief 
point  of  interest  to  us  being  that  both  the  mitral  and  tricuspid  lesions 
were  noted. 

But  though  mitral  regurgitation  is  comparatively  easy  to  diag- 


54  Mitral  Insufficiency 

nosticate,  it  is  unsafe  to  pin  our  faith  too  exclusively  on  ausculta- 
tory murmurs,  as  indicative  of  organic  disease.  For  occasionally 
functional  mumuirs  are  produced  at  the  apex,  by  the  patient's  pos- 
ture or  other  causes.  These  murmurs,  however,  are  not  apt  to  be 
accompanied  by  an  accentuated  secondary  pulmonary  sound.  They 
may  also  be  due  to  impoverished  blood  or  muscular  vibration.  Ow- 
ing to  the  extreme  rarity  of  a  tricuspid  insufficiency  (according  to 
my  records  about  4  per  cent.),  it  is  apt  to  be  disregarded  in  practice. 
It  may,  however,  be  combined  with  mitral  insufficiency,  as  in  Case 
VI.  It  is,  however,  difficult  of  diagnosis,  not  only  because  the 
centre  of  the  tricuspid  area  is  tolerably  close  to  the  mitral, but  the  two 
areas  overlap  to  some  extent.  In  uncomplicated  cases  of  tricuspid 
insufficiency,  however,  there  is  no  accentuation  of  the  second  pulmon- 
ary sound ;  the  systolic  nmrmur  is  not  conveyed  to  the  left  as  much 
as  it  is  to  the  right ;  there  is  venous  pulsation  of  the  veins  in  the  neck, 
and  a  dilated  right  heart. 

In  instances  where  there  are  merely  fresh  vegetations  on  the 
valves  sufficient  to  cause  very  slight  insufficiency  no  murmur  may 
exist.  After  all,  mitral  insufficiency  is  comparatively  easy  to  de- 
termine, because  the  valve  is  to  the  left  and  behind,  and  as  the  mur- 
mur follows  the  regurgitant  current,  which  flows  more  or  less  back- 
ward as  it  goes  upward,  it  is  carried  somewhat  towards  the  angle 
of  the  left  scapula.  In  my  experience  the  diagnosis  of  pure  mitral 
insufficiency  is  made  in  three  quarters  of  the  cases. 

The  treatment  is  coub-idered  in  Chapter  XIX. 


Chapter  V. 

MITRAL  OBSTRUCTION.! 

Our  conceptions  of  mitral  obstruction  originated  with  Corvisart, 
Napoleon's  able  physician,  and  the  teacher  of  Laennec,  who  tells 
us  that  in  1819  Corvisart  first  called  attention  to  the  "purring  thrill" 
of  mitral  obstruction,  which  he  described  as  a  "particular  sensation, 
which  in  some  cases  is  perceptible  to  the  hand  when  this  is  applied 
to  the  region  of  the  heart,"  and  is  a  "sign  of  the  ossification  of  the 
valves,  and  particularly  of  the  mitral  valve.  Indeed,  this  phenom- 
enon is  observed  in  almost  every  case  in  which  there  is  some  con- 
traction of  the  auricle  of  the  heart."  Leaving  out  of  consideration 
Laennec's  erroneous  views  about  "ossification,"  it  is  enough  to  note 
that  he  clearly  associated  the  discovery  of  the  "purring  thrill"  with 
his  distinguished  teacher. 

He  is  also  equally  emphatic  in  attributing  the  discoverv  of  the 
diastolic  bruit  of  mitral  obstruction  to  his  contemporary,  Bertin,  but 
the  description  of  it  is  all  his  own.  Alluding  to  one  of  his  personal 
cases,  he  uses  these  words:-  "The  contraction  of  the  auricle,  which 
was  extremely  prolonged,  was  performed  with  a  dull  but  strong 
sound,  precisely  resembling  that  produced  by  filing  wood.  This  was 
accompanied  by  a  vibration  sensible  to  the  ear,  and  is  evidentlv 
the  same  as  is  felt  by  the  hand.  At  the  close  of  the  contraction 
one  could  distinguish  by  a  louder  sound,  accompanied  by  an  impulse 
and  perfectly  synchronous  with  the  pulse,  the  contraction  of  the 
ventricle,  which  w^as  three-fourths  shorter."  Three  cases  of  this 
kind,  he  tells  us,  had  been  described  by  Bertin,  and  were  verified  by 
autopsies. 

Twenty-four  years  later  Fauvel  first  called  attention  to  the  sub- 
variety  of  diastolic  bruit  now  known  as  the  presystolic,  which  he 
defined  as  a  "loud,  rasping  bruit"  preceding  the  first  sound  or  mur- 
murmur  and  ending  with  it.  In  English  circles  W.  T.  Gairdner.^'  of 
Edinburgh,  is  usually  credited  with  defining  it,  which  he  did  under 
the  name  "auricular  systolic  bruit."  According  to  Gairdner.  it 
was  a  murmur  preceding  the  first  sound,  running  sharply  up  to  it, 
then  coming  abruptly  to  a  stop. 


^  Originally  published  in  the  A^.  Y.  Med.  Journal,  May  10,  1902. 
^Mediate    auscultation,  London,  1846,  pp.  555  and  617. 
*  Clin.  Med.,  1862,  p.  598. 


56  Mitral  Obstruction 

Obstruction  at  the  left  auriclo-ventricular  orifice,  which  for  con- 
venience sake  rather  than  because  it  is  the  best  term,  has  been  called 
mitral  stenosis,  is  not  a  very  uncommon  lesion.  Walshe*  puts  it 
fourth  in  his  list  which  is  as  follows : 

1.  Mitral  insufficiency. 

2.  Aortic  stenosis   (obstruction). 

3.  Aortic  insufficiency. 

4.  Mitral   stenosis    (obstruction). 

5.  Tricuspid  insufficiency. 

6.  Pulmonary    insufficiency. 

7.  Pulmonary  stenosis    (obstruction). 

It  also  occupies  the  same  position  in  one  of  my  lists  (sixty-five 
valvular  cases)  verified  by  autopsies,  which  is  as  follows: 

1.  Aortic  insufficiency,  49  times. 

2.  Aortic  stenosis  (obstruction).  39  times. 

3.  Mitral  insufficiency,  38  times. 

4.  Mitral  stenosis  (obstruction),  33  times. 

5.  Tricuspid  insufficiency,  8  times. 

6.  Tricuspid  stenosis  (obstruction),  4  times. 

7.  Pulmonary  insufficiency,  4  times. 

One  hundred  and  seventy-five  valve  lesions  in  65  autopsies. 

And  in  fifty  cases  taken  from  my  clinic  by  myself  or  assistants 
(not  verified,  of  course,  by  autopsies),  the  incidence  as  to  mitral 
obstruction  was  the  same,  being: 

1.  Mitral  insufficiency. 

2.  Aortic  insufficiency. 

3.  Aortic  obstruction  (stenosis). 

4.  Mitral  obstruction  (stenosis). 

5.  Tricuspid  insufficiency. 

6.  Pulmonary  insufficiency.^ 

It  may  be  laid  down  as  a  fact  that  mitral  obstruction  in  general 
implies  regurgitation,  though  the  mitral  regurgitant  murmur  is  apt 
to  be  absent  in  the  later  stages  of  obstruction.  In  the  sixty-five  cases 
alluded  to  they  coexisted  in  45  or  70  per  cent.  In  fact,  advanced 
obstruction  seems  to  be  almost  impossible  without  regurgitation ; 
certainly  in  stenosis,  where  the  orifice  or  leaflets  or  their  attach- 
ments are  rigid. 

On  the  other  hand,  regurgitation  not  infrequently  occurs  with- 
out obstruction,  as  for  example,  in  the  early  stages  of  organic  in- 


*  Diseases  of  the  Heart,  London,  1873,  p.  T05. 

°  Endocardiopathies,  Virginia  Med.  Semi-monthly,  April  26,  1901. 


Mitral  Obstruction  57 

sufficiency  and  in  all  cases  of  the  relative  variety.  The  relation  of 
obstruction  to  regurgitation  is  sometimes  close,  according  to  my 
figures,  and  yet  it  is  variable.  There  is  clearly  a  sequential  relation 
between  the  two,  regurgitation  being  as  a  rule  preliminary  to  ob- 
struction, and  subsequently  its  associate.  So  far  from  the  stand- 
point of  pathological  anatomy. 

Clinically,  there  is  also  a  close  relation  between  the  two,  but  the  in- 
terest of  the  physician  turns  chiefly  on  the  determination  of  which 
is  the  predominating  disease.  On  this  point  hangs  the  prognosis, 
for  mitral  regurgitation  has  a  comparatively  favorable  outlook,  while 
mitral  obstruction  seriously  modifies  the  expectation  of  life. 

Well  marked  mitral  obstruction  is,  however,  somewhat  rare.  In 
seventy-one  instances,  complete  as  to  clinical  histories  and  autopsies, 
taken  by  myself  from  French,  English  and  American  authors  (not 
including  my  own  cases),  advanced  obstruction  occurred  in  only 
thirty-eight,  or  about  53  per  cent.  In  twenty-nine  of  my  personal 
cases  the  severe  ones  were  nine,  or  only  31  per  cent.  The  larger 
ratio  in  the  foreign  cases  is,  perhaps,  because  rheumatic  affections 
are  more  common  abroad,  especially  in  Great  Britain,  than  in  this 
country.  So  that,  on  the  whole,  the  severe  cases  average  some- 
what less  than  one-half  the  total.  But  it  is  in  this  class  that  we 
encounter  the  greatest  difficulty  in  diagnosis,  because  the  diastolic 
murmurs  are  apt  to  be  faint.  How  great  this  difficulty  has  been  may 
be  judged  from  the  records  of  the  Massachusetts  General  Hospital, 
where,  as  late  as  1900,  in  forty-eight  cases  of  mitral  obstruction, 
;as  proved  by  autopsies,  but  twenty -three,  or  45  per  cent.,  were  rec- 
ognized during  life.  (Cabot,  Phys.  Diag.,  New  York,  1900,  p. 
163.) 

Another  reason  for  failure  in  diagnosis  (other  than  the  one 
^iven)  is,  as  was  intimated  at  the  outset,  that  the  data  on  which  to 
iDase  rules  for  diagnosis  have  been  defective.  An  instance  is  well 
shown  by  Fagge,*'  who  tells  us  that  previous  to  1871  there  were 
but  twenty-eight  cases  on  record  where  presystolic  murmurs  had 
been  found,  on  post-mortem  examination,  to  have  been  associated 
with  mitral  obstruction.  And  yet  this  sub-variety  of  the  diastolic 
murmur  had  been  known  for  upwards  of  thirty  years,  in  fact  since 
1843. 

Speaking  broadly,  there  is  a  wide  difference  between  the  gen- 
•eral  effect  on  the  heart  and  system  at  large,  between  chronic  ob- 
struction and  chronic  insufficiency.     In  the  former  systolic  contrac- 


Guy's  Hospital  Reports,  31,  Ser.  3,  16,  1871. 


58  Mitral  Obstruction 

tion  of  the  left  ventricle  fails  to  force  a  requisite  quantity  of  blood 
into  tlie  aorta,  because  part  of  it  escapes  through  the  leak  in  the  mi- 
tral valve.  To  overcome  this  dilTiculty  the  left  ventricle  hyper- 
trophies and. remains  hypertrophied  as  long  as  the  leak  is  consider- 
able ;  but  as  chronic  insufflcienc}'  passes  over  into  chronic  stenosis, 
so  the  hypertrophied  left  ventricle  synchronously  finds  its  task  more 
easy  until  at  length,  if  the  patient  survive,  the  orifice  is  so  reduced 
as  to  represent  nothing  but  a  chink  or  cleft,  and  the  leak  is  no  longer 
considerable.  But  now  the  blood  is  very  greatly  delayed  in  its  pas- 
sage from  the  left  auricle,  and  an  undue  quantity  is  detained  there. 
Dilatation  and  hypertrophy  of  the  left  auricle  naturally  ensue,  for 
greater  force  must  be  used  by  the  auricle  to  expel  the  blood  during 
each  diastolic  interval. 

Assuming,  then,  that  chronic  insufficiency  of  the  mitral  precedes 
chronic  obstruction,  this  change  in  the  walls  of  the  left  auricle  is 
the  second  of  the  series.  The  third  is  the  arrest  in  the  hypertro- 
phy of  the  left  ventricle,  or  even  an  atrophy,  due  to  the  fact  that 
the  insufficiency  has  been  succeeded  by  stenosis   (obstruction). 

The  accumulation  of  blood  in  the  left  auricle,  and  the  consequent 
backing  of  the  venous  blood  into  the  lungs,  produce  in  turn  hyper- 
trophy of  the  right  ventricle,  because  more  work  is  thrown  on  it. 
If,  however,  this  ventricle  finds  itself  incompetent  for  the  task  and 
dilates,  the  tricuspid  valves  will  also  stretch  and  hypertrophy,  and 
dilatation  of  the  right  auricle  will  follow.  The  vicious  circle  is  then 
complete. 

At  and  beyond  a  certain  grade  of  obstruction,  therefore,  the  in- 
sufficiency is  relieved.  Unfortunately  a  substitution  of  the  one 
for  the  other  does  not  improve  the  expectation  of  life.  But  it  em- 
phasizes the  importance  of  combatting  the  systemic  disease  at  an 
early  period  by  treatment  directed  to  preventing  continued  infiltra- 
tion of  the  valves  and  their  attachments,  because  there  appears  to- 
be  no  controlling  influence  in  nature  to  counteract  it.  In  this  con- 
nection I  believe  I  may  say  that  the  profession  is  hardly  willing 
to  seriously  consider  Balfour's  suggestion  of  opening  the  heart  and 
cutting  the  constriction.  Even  supposing  this  procedure  were  prac- 
ticable, it  could  not  arrest  the  constitutional  process  which  produced 
the  stenosis. 

The  following  cases,  taken  from  my  records,  illustrate  some  of 
the  points  I  have  made. 

Case  VII.  Aortic  and  Mitral  Disease. —  ,  aged  thirty- 
one.     Admitted  to  hospital  October  23,   1885.      The  patient  com- 


Mitral  Obstruction  59 

plained  simply  of  dyspnoea  and  rheumatic  pains.  On  examination 
the  heart's  action  was  found  to  be  rapid  and  irregular.  There  was 
a  systolic  murmur  at  the  apex  conveyed  to  the  left.  Death  took 
place  after  fourteen  hours'  stay  in  the  hospital.  At  the  autopsy 
the  heart  was  found  to  weigh  18  oz.  The  mitral  was  dilated  and 
the  tendinous  chords  and  margins  of  the  valves  were  covered  with 
vegetations.  Mitral  orifice  dilated  so  as  to  admit  three  fingers  Ttwo 
^ngers  being  the  ordinary  size  of  the  opening).  Aortic  valves 
thickened  and  the  seat  of  vegetations,  but  sufficient.  Pericardial  sac 
contained  4  oz.  of  serum.  Left  ventricle  hypertrophied  and  dilated. 
Right  ventricle  not  hypertrophied.  Lungs  oedematous.  Kidneys 
Di  the  large,  white  variety.      Infarctions  of  spleen. 

Now,  such  a  case  as  this  I  hold  to  be  in  a  stage  preliminary  to 
obstruction  (stenosis),  though  as  a  matter  of  fact  the  orifice  was 
really  dilated.  But  given  a  mass  of  vegetations  about  any  valve, 
let  them  continue  to  develop,  and  the  patient  will  surely  have  steno- 
sis if  the  disease  continues  and  he  lives  long  enough.  In  this  case 
the  aortic  disease  appears  to  have  been  insignificant  as  compared  with 
the  mitral,  the  aortic  valves  being  classed  as  sufficient ;  so  that  the 
hypertrophy  of  the  left  ventricle  may  be  fairly  charged  to  the  mitral 
insufficiency. 

On  the  other  hand,  the  following  case.  No.  VIII,  may  be  re- 
garded as  one  of  tolerably  advanced  obstruction  in  which  the  re- 
gurgitant element  was  supplanted  by  the  obstructive.  We  ob- 
serve that  the  heart  in  this  case  was  small  as  compared  to  No.  VII. 
There  was  no  hypertrophy  of  the  left  ventricle,  but  the  dilatation 
pf  both  the  right  auricle  and  right  ventricle  indicated  that  the 
anatomical  changes  had  shifted  over  from  the  left  to  the  right 
side,  as  was  to  be  expected  in  this  particular  case  of  valvular 
lesion. 

Case  VIII.     Mitral  Obstruction  (Stenosis)  and  Regurgitation. — - 

,  aged  thirty-eight,  teacher,  was  admitted  to  hospital  Nov. 

19,  1 89 1.  About  a  month  before  admission  she  was  taken  with 
dyspnoea,  weakness,  dyspepsia  and  epigastric  pain.  On  a  first  ex- 
amination, a  bruit  preceding  the  first  sound  was  heard  at  the  apex. 
and  it  was  propagated  to  the  middle  of  the  axilla,  so  it  was  thoughts 
At  any  rate,  a  correct  diagnosis  of  mitral  regurgitation  and  steno- 
sis was  finally  made.  About  a  week  after  admission  she  was  taken 
with  spitting  of  blood  and  rales,  and  cogwheel  respiration  was  heard 
at  the  base  of  the  right  lung.  On  November  29th  the  patient's 
mind   became   affected.       Pulse   moderately   strong,   but   irregular. 


6o  Mitral  Obstruction 

Delirium  ensued  and  then  death.  At  tiie  post-mortem  examination 
20  oz.  of  fluid  were  found  in  the  peritoneal  cavity.  There  were 
hemorrhagic  infarctions  in  both  lungs.  Weight  of  heart  8  oz. 
Right  ventricle  dilated.  Tendinous  chords  contracted.  Mitral  did 
not  admit  a  single  finger.  No  liypertrophy  of  left  ventricle.  Aor- 
tic normal.  Pulmonary  valve  a  little  tliickened  and  dilated.  Right 
auricle  dilated.  Nutmeg  liver.  This  case  is  a  good  example  of 
the  changes  that  may  be  found  in  the  heart  and  system  at  large,  in 
the  middle  period  of  mitral  obstruction,  after  compensation  has 
been  established. 

It  is  astonishing  how  small  the  orifice  may  become.  I  have 
occasionally  seen  it  so  reduced  that  it  would  not  admit  the  little 
finger. 

During  the  first  period  where  there  is  hypertrophy  of  the  left 
ventricle,  the  apex  is  carried  out  to  or  perhaps  beyond,  the  nipple, 
but  as  this  ventricle  contracts  the  apex  recedes  within  the  nipple 
line,  usually  remaining  within  it  during  the  course  of  the  disease, 
unless  there  is  some  complication,  such  as  the  common  one,  aortic 
<iisease. 

When  in  a  subsequent  stage  the  right  ventricle  is  enlarged  and 
begins  to  labor,  it  thumps  against  the  wall  of  the  chest  and  its  in- 
creased breadth  is  recognized  by  percussion.  It  may  extend  as 
much  as  two  inches  beyond  the  right  sternal  border.  But  with  all 
these  changes  the  heart  is  seldom  much  enlarged,  for  in  uncompli- 
cated cases  it  will  average  in  weight  from  15  to  18  oz.  only. 

In  Dyce  Duckworth's  cases  (St.  Bartholomezv's  Hospital  Re- 
ports, 13,  263),  264  in  number  (though  in  many  the  ante-mortem 
diagnosis  was  not  verified  by  autopsies),  the  average  age  was  thirty- 
five.  In  my  first  series  of  100  cases  I  found  the  limit  of  age  seven- 
teen and  seventy-eight,  but  68  per  cent,  of  them  died  under  forty, 
and  at  the  average  age  of  thirty-five.  In  the  second  series  the  aver- 
age age  was  thirty-three.  Sansom  (Albutt's  System,  p.  908,  Vol.  6) 
found  the  average  age  of  death  32.7  years. 

There  has  been  a  disposition  among  English  writers,  particu- 
larly, to  state  that  the  female  sex  is  most  often  affected.  In  Broad- 
bent's  fifty-three  autopsies,  according  to  Sansom,  there  were  thirty- 
eight  females  to  fifteen  males.  In  a  series  of  seventy  cases,  how- 
ever, I  have  found  that  the  preponderance  of  females  was  not  note- 
worthy (thirty-six  to  thirty-four),  and  Sansom's  seventeen  autop- 
sies have  given  the  proportion  of  only  ten  females  to  seven  males. 


Mitral  Obstruction  6i 

The  value  of  the  pulse  by  itself  as  a  diagnostic  factor  is  small. 
Walshe,  already  quoted,  speaks  of  it  as  regular.  James  Andrew 
(St.  Bartholomew's  Hospital  Reports,  13,  1877)  makes  it  small, 
rapid  and  irregular.  As  a  matter  of  fact,  it  will  be  irregular  until 
compensation  is  well  established,  but  regular  during  well-sustained 
compensation,  and  irregular  again  with  faiHng  compensation.  But 
in  all  stages  it  is  apt  to  be  small  and  feeble  at  the  last;  becoming 
intermittent  with  irregular  rhythm,  which  is  often  in  marked  con- 
trast to  the  prevailing  strong  or  heaving  cardiac  impulse. 

The  characteristic  presystolic  murmur  associated  in  our  minds 
with  mitral  obstruction  has  various  qualities.  It  is  sometimes 
spoken  of  as  "rumbling"  or  "rolling,"  but  in  my  experience  it  is 
more  often  loud  and  "rasping,"  or  "sawing,"  though  it  may  have 
other  qualities  and  be  faint  or  barely  audible.  It  is  contemporane- 
ous with  the  thrill,  if  there  be  any,  and  indicates  the  passage  of 
blood  from  the  auricle  into  the  left  ventricle  in  the  diastolic  inter- 
val. The  murmur  may  occupy  the  whole  of  this  interval  or  any 
part  of  it.  In  fact,  there  may  be  a  double  diastolic  murmur. 
Though,  properly  speaking,  all  diastolic  murmurs  are  presystolic, 
the  term  presystolic,  by  common  acceptance,  is  limited  to  those  at  the 
extreme  end  of  diastole.  This  murmur  may  come  or  go.  When 
the  patient  is  weak  or  the  orifice  small,  it  may  be  impossible  to 
hear  any  murmur.  Again,  other  murmurs  may  mask  it.  In  twen- 
ty-seven of  my  own  cases,  proved  by  autopsies,  I  found  the  presys- 
tolic murmur,  which  presumably  existed 

heard   in    4  r=:     15  per  cent. 

not  heard   in  19  ^     70  per  cent. 

falsely  interpreted  in    4  r=     15  per  cent. 

27  z=  100  per  cent. 

In  Fagge's  series  of  forty-seven  cases  a  presystolic  murmur 
was  noted  in  only  seven,  or  15  per  cent.,  which  tallies 
wdth  my  experience.  On  the  other  hand,  Sam  ways,  in  156  cases 
as  proved  by  post-mortems  at  St.  Bartholomew's  Hospital  (British 
Med.  Jour.,  1898,  i,  p.  36),  found  a  presystolic  murmur  audible 
in  about  60  per  cent.,  and  in  Hayden's  fifteen  autopsies  it  w^as  noted 
in  twelve,  or  80  per  cent.  However,  in  the  latter's  total  of  eight3'-one 
cases  sixty-six  were  not  confirmed  by  autopsies.  In  eight  of  Fagge's 
twenty-eight  cases  there  was  a  double  murmur,  diastolic  in  char- 
acter. In  other  words,  there  was  a  diastolic  murmur  in  28  per  cent, 
apart  from  the  presystolic,  which  was  15  per  cent.,  so  that  the  total 


62  Mitral  Obstruction 

of  his  murmunrs  in  the  cliastohc  interval  was  43  per  cent     In  a 
series  of  twenty  cases  I  found 

a  simple  mitra\  presystolic  inurniur   in     3  rrr     15  per  cent. 

simple  systolic  in  4  =     20  per  cent. 

presystolic  and  systolic  in  5  =     25  per  cent. 

no  murmurs  in  8  =r     40  per  cent. 

20  =   100  per  cent. 

From  my  figures,  therefore,  it  appears  that  the  simple  presys- 
tolic murmur  was  noted  in  only  15  per  cent.,  the  systolic  in  20  per 
cent.,  the  double  murnuir  in  25  per  cent.,  or  a  total  of  diastolic 
nuirmurs  equaling  40  per  cent.  My  figures  agree,  therefore,  pretty 
nearly,  with  those  of  Fagge. 

In  one  of  my  twenty-seven  cases,  the  presystolic  munnur,  it  was 
stated,  was  carried  to  the  left  of  the  nipple,  in  another  to  the  axilla ; 
in  two  it  was  heard  as  high  as  the  second  rib ;  usually  is  was  about 
at  the  apex.  Probably  in  the  case  where  it  was  said  to  have  been 
carried  to  the  axilla  it  was  confounded  with  a  systolic  murmur. 
In  one  instance  it  was  confounded  with  a  Flint  murmur  carried 
down  from  the  aorta  to  the  apex,  and  in  this  particular  case  the 
aortic  leaflets  were  so  distorted  as  to  make  the  explanation  of  Sir 
Walter  Foster  apply,  namely,  that  the  sound  was  caused  by  the 
aortic  stream  impinging  on  a  stiff  mitral  leaflet.  But  there  may  be 
no  murmur,  as  I  have  indicated,  and  as  the  following  case  shows : 

Case  IX.  Mitral  Obstruction,  Anceniia,  etc. ,  aged  thir- 
ty-two, domestic,  was  admitted  to  hospital  Jan.  22,  1877.  She  was 
the  mother  of  eight  children.  About  a  week  before  admission  her 
urine  became  scant}^  and  there  was  a  swelling  of  her  abdomen.  She 
had  orthopnoea,  anasarca,  uraemia  and  cyanosis.  Pulse  weak  and 
intermittent,  heart  sounds  faint  and  irregular  No  murmurs.  On 
?>Iarch  31st  she  was  discharged  improved,  but  was  readmitted  on 
May  22d  with  a  return  of  symptoms.  She  died  two  days  later,  of 
erysipelas.  At  the  post-mortem  examination  the  right  ventricle  and 
auricle  were  found  dilated  and  thin.  Stenosis  (obstruction)  of  mi- 
tral with  extensive  calcareous  deposits.  Aortic  thickened,  but  not 
rough.  Pulmonary  and  tricuspid  normal.  Weight  of  heart,  19  oz. 
l^ungs  oedematous.     Kidneys  granular  and  pigmented.  . 

The  absence  of  murmurs  when  examination  was  made  is  com- 
prehensible, w^hen  we  consider  her  weak  condition,  and  that  she  was 
in  the  final  stages  of  mitral  obstruction. 

To  distinguish  between  the  mitral  obstructive  and  the  aortic  re- 
gurgitant, feel  the  carotid  pulse  and  not  the  radial,  which  is  later 


Mitral  Obstruction  63 

than  the  carotid ;  then  carry  your  stethoscope  by  successive  steps 
from  the  base  to  the  apex,  and  you  are  certain  to  determine  which 
is  the  first  and  which  the  second  sound. 

It  is  important  also  to  note  if  there  is  a  pecuhar  quahty,  pitch  or 
duration  or  intensity  in  either  murmur.  If  there  is  it  will  help  to 
distinguish  the  one  from  the  other. 

W.  S.  Thayer  (American  Journal  of  the  Medical  Sciences,  No- 
vember 19,  1901,  p.  538),  however,  from  a  study  of  74  cases  of 
aortic  insufficiency,  where  the  lesion  was  determined  by  post-mortem 
examinations,  has  concluded  that  "in  uncomplicated  cases  of  aortic 
insufficiency  a  rumbling,  echoing,  presystolic  or  mid-diastolic  mur- 
mur, limited  to  the  region  of  the  apex,"  occurs  in  fully  half  these 
cases  (Medical  Record,  January  18,  1902),  from  which  it  would 
appear  that  the  value  of  the  presystolic  or  diastolic  murmur  as  a 
sign  of  mitral  obstruction  is  not  so  great  as  has  been  held. 

There  are  other  signs  of  aortic  disease,  such  as  the  "long  heart," 
Corrigan  pulse,  and  dilated  aorta,  that  assist  in  the  diagnosis  of 
aortic  insufficiency,  while  the  aortic  direct  murmur  is  carried  up- 
ward into  the  vessels  of  the  neck. 

From  my  two  series  of  cases  I  gather  that  a  purring  thrill  exists 
in  from  10  to  35  per  cent.  Samways,  in  196  cases,  found  the  thrill 
in  less  than  33  per  cent.  It  is  usually  noted  in  the  fourth  left  space, 
sometimes  in  the  fifth  or  sixth,  again  in  the  fifth,  sixth  and  seventh. 
The  thrill  in  this  situation  probably  always  denotes  stenosis  of  the 
mitral  or  implication  of  some  other  valve,  usually  the  aortic.  So 
far  as  the  mitral  is  concerned,  it  means  that  the  opening  is  small. 
The  thrill  continues  through  the  period  of  effectual  compensation ; 
indeed,  a  strong  thrill  means  good  compensation,  and  loss  of  thrill 
heartweakness.  The  accentuation  of  the  second  sound  over  the 
pulmonary  is  a  very  important  sign.  It  indicates  that  the  left  auri- 
cle is  over-filled,  the  extreme  back  pressure  from  the  blood  in  the 
auricle  against  the  pulmonary  valve  causing  the  accentuation  of 
the  second  pulmonary  sound.  Epigastric  pulsation  is  a  late  symp- 
tom. It  is  usually  associated  with  a  large,  tender  and  pulsating 
liver,  and  is  an  unfavorable  sign,  indicating  that  compensation  is 
failing  and  the  right  side  of  the  heart  becoming  involved,  so  that 
dropsical  efifusions  are  not  ofif. 

Embolism  is  a  special  feature  of  mitral  obstruction,  as  Cases  X 
and  XI  show. 

Case  X.     Mitral  Obstruction;  Embolic  Pneumonia. —  , 

aged  twenty-eight,  widow,  was  admitted  to  hospital  Dec.  20,  1877. 
She  had  suffered  from  cough  for  five  years,  and  seven  years  from 


6/  Mitral  Obstruction 

heart  trouble.  Eight  }ears  previously  had  an  attack  of  inflamma- 
tory rheumatism.  The  patient  was  found  on  admission  to  be  anaemic 
and  much  emaciated.  Breathing  short  and  rapid,  cough  with 
frothy  expectorations,  pulse  120,  temperature  101.2°  F.  On  exam- 
ination, she  was  found  to  be  in  the  third  stage  of  phthisis.  Heart's 
action  weak,  but  not  out  of  proportion  to  her  general  debility.  No 
organic  lesion  discovered.  Patient  developed  uraemia  suddenly  and 
died  Dec.  22d.  At  the  autopsy  the  heart  was  found  to  weigh  14 
oz.  and  was  stated  to  be  normal,  except  as  to  the  mitral,  which  had 
a  button-hole  opening  three-quarters  of  an  inch  long,  in  its  longest 
diameter.  The  lungs  were  the  seat  of  embolic  pneumonia.  Liver 
atrophic  and  nutmeg.     Cause  of  death,  embolic  pneumonia. 

But  cerebral  embolism  may  also  cause  death,  as  in  the  following 
case: 

Case      XL        Mitral      Obstruction;      Cerebral      Embolism. — 

,     aged     fifty,     clerk,     was     admitted     to     hospital     Dec. 

12,  1883.  He  had  suffered  from  many  attacks  of  inflamma- 
tory rheumatism.  In  1882  there  appeared  symptoms  of  slight  cere- 
bral embolism  as  shown  by  aphonia,  which  lasted  two  days.  On  en- 
tering the  hospital  he  was  found  to  have  dyspnoea  and  abdominal 
pain  with  consolidation  at  the  apex  of  the  right  lung.  There  were 
also  murmurs  at  the  apex  of  the  heart  with  the  first  sound,  and  at 
the  base  with  the  second  sound.  Albumin  and  granular  casts. 
Pulse  strong  and  regular,  later  becoming  weak  and  irregular,  dur- 
ing an  intercurrent  attack  of  rheumatism  with  uraemia  and  pulmon- 
ary oedema.  At  post-mortem  examination  the  heart  was  found  to 
weigh  27^  oz.  Hypertrophy  of  both  ventricles.  The  mitral  had 
a  button-hole  opening  and  was  insufficient.  Oedema  and  brown 
induration  of  the  lungs.  Chronic  diffuse  nephritis.  Enlarged 
and  pigmented  liver.  Death  was  attributed  to  cerebral  em- 
bolism. 

In  18  per  cent,  of  my  first  series  of  100  cases  the  rhythm  was 
irregular.  In  20  per  cent,  of  my  second  series  it  was  also  irregular. 
In  one  there  was  a  double  rhythm ;  in  one  a  quadruple  rhythm.  In 
several  there  was  a  gallop  rhythm.  The  cardiac  impulse  may  be 
ill  defined  or  diffuse,  heaving  or  strong,  and  the  impulse  may  be 
carried  to  the  epigastrium.  In  well  established  compensation  the 
heaving  is  due  to  hypertrophy  of  the  right  ventricle.  A  noteworthy 
sign  of  mitral  obstruction  to  which  little  attention  has  been  given 
is  the  pretty  constant  relation  of  a  strong  cardiac  impulse  to  a  weak 
radial  pulse. 


Mitral  Obstruction  65 

There  has  been  some  effort  to  divide  mitral  obstruction  into 
three  stages  based  on  auscultatory  signs  (Broadbent,  3rd  edition, 
T900),  though  as  these  signs  are  not  closely  associated  wtih  the 
stages  it  is  a  difficult  task.  It  is  more  in  accord  with  present  meth- 
ods to  divide  this  affection  into  stages  on  an  anatomical  basis.  This 
is  not  altogether  satisfactory,  but  1  have  endeavored,  somewhat 
roughly,  in  the  cases  used  for  illustration,  to  indicate  that  there 
may  be  a  preobstructive  stage,  and  early,  middle  and  late  stages. 

In  fact,  I  have  already  described  the  anatomical  changes  which 
take  place  in  the  evolution  of  a  case  of  uncomplicated  mitral  ob- 
struction. According  to  this  view  we  have  at  first  simply  the  signs 
of  mitral  insufficiency.  Then  when  those  of  insufficiency  give 
way  to  those  of  obstruction  the  right  ventricle  becomes  hypertro- 
phied  and  the  impulse  is  "thumping"  or  strong.  In  a  certain  pro- 
portion of  cases  there  is  a  thrill  and  a  diastolic  murmur,  perhaps  a 
presystolic ;  and  a  sharp,  "tapping"  first  sound  at  the  apex.  In  the 
last  stage,  when  compensation  fails,  the  presystolic  murmur  disap- 
pears, because  the  auricle  has  no  longer  strength  to  drive  its  col- 
umn of  blood  into  the  left  ventricle.  The  right  auricle  becoming  di- 
lated through  the  giving  way  of  the  tricuspid,  causes  pulsation  in 
the  veins  of  the  neck.  Dyspncea,  dropsy,  and  pulmonary  cedema 
then  supervene.  This  last  stage  is  well  shown  in  the  following 
case: 

Case    XII.     Mitral    Obstruction;    Pulmonary    Oedema,    etc. — 

,  aged  thirty-seven,  plasterer,  was  admitted  to  the  hospital 

May  20,  1879.  Three  weeks  before  admission  his  feet  began  to 
swell.  General  anasarca  followed,  with  debility,  scanty  urine,  and 
pulmonary  oedema.  The  heart  was  hypertrophied,  but  no  signs 
were  noted  expect  those  of  mitral  insufficiency.  No  second  sound 
was  audible.  Pulse  40.  Under  appropriate  treatment  he  im- 
proved and  was  discharged.  Bvit  in  less  than  a  month  he  was  re- 
admitted with  a  recurrence  of  the  symptoms,  culminating  m  sup- 
pression, of  which  he  died.  At  the  post-mortem  examination  there 
was  found  general  anasarca,  with  12  oz.  of  fluid  in  the  pericardial 
sac.  Heart  hypertrophied,  weighing  22  oz.  Aortic  and  pulmonary 
^/alves  free.  Mitral  a  mass  of  atheroma,  with  a  small  button-hole 
opening,  causing  both  obstruction  and  insufficiency.  Lungs  oede- 
matous.  Kidneys  enlarged  and  congested.  Liver  atrophic,  but 
pigmented. 

In  mitral  obstruction  there  is  great  danger  of  embolism,  not  so 
much  from  the  diseased  valves  as  from  clots  that  become  entangled  in 


()lo  Mitral  Obstruction 

the  interstices  between  the  tendinous  chords  and  papillary  muscles 
during  imperfect  cardiac  action. 

The  following-  points  appear  from  my  tables : 

1.  Mitral  obstruction  is  usually  fatal  before  the  age  of  forty  is 
reached. 

2.  Females  are  little  more  prone  to  it  than  males. 

3.  There  is  apt  to  be  a  marked  contrast  between  a  strong  car- 
iliac  impulse  and  a  feeble  radial  pulse. 

4.  The  true  presystolic  murmur  occurs  in  15  per  cent.  It 
•comes  and  goes ;  but  it  is  usually  inaudible  in  the  last  stage. 

5.  It  is  apt  to  have  a  loud,  rasping  or  sawing  quality,  but  may 
he  "gushing"  or  "whirring."      It  may  also  be  faint. 

6.  In  about  40  per  cent,  there  is  some  sort  of  a  diastolic  murmur. 

7.  These  murmurs  are  best  heard  over  a  rather  limited  area, 
somewhat  oval  in  form,  having  for  its  centre  a  point  about  over  the 
middle  of  the  5th  left  intercostal  cartilage,  and  about  midway  be- 
tween the  nipple  and  the  ensiform  appendix.  The  breadth  of  this 
area  may  be  two  to  three  inches  and  its  vertical  length  five  to  seven. 
The  murmur  is  sometimes  heard  best  as  low  as  the  fifth,  sixth  or 
€ven  seventh  left  space ;  more  rarely  it  is  heard  as  high  as  the  second 
left  rib. 

8.  In  10  to  35  per  cent,  there  is  a  thrill  over  this  area. 

9.  The  first  sound  at  the  apex  is  short  and  abrupt. 

10.  The  second  pulmonary  sound  at  the  base  is  usually  intensified. 

11.  Occasionally  a  murmur  with  the  second  sound  at  the  base  is 
heard  over  the  left  auricular  appendix. 

12.  At  first  there  is  dilatation  and  hypertrophy  of  the  left  ven- 
tricle. Then  atrophy  of  it,  with  dilatation  and  hypertrophy  of  the 
left  auricle ;  then  follow  dilatation  and  hypertrophy  of  the  right 
heart. 

13.  ]\Iitral  insufficiency  must  to  some  extent  precede  or  accom- 
pany mitral  obstruction. 

14.  In  distinguishing  the  presystolic  murmur  of  mitral  obstruc- 
tion from  the  Flint  murmur  of  aortic  insufficiency  we  should  rely 
on  the  "long  heart"  and  the  strong  impulse,  or  the  "Corrigan"  of 
insufficiency,  rather  than  auscultatory  signs.  In  case  there  is  both 
aortic  insufficiency  and  mitral  obstruction  a  differential  diagnosis 
is  impossible,  with  the  means  we  now  have  at  our  command,  unless 
we  can  recognize  some  distinguishing  qualities  in  the  murmuri:  at  the 
two  openings. 


Chapter  VI . 

DISEASES  OF  THE  AORTIC  VALVE. 

Of  all  cardiac  valves  the  mitral  and  aortic  suffer  most  in 
endocarditis,  but  there  has  been  a  divergence  in  opinion  as  to  which 
of  these  is  most  often  affected.  According  to  Sperling's  tables, 
however,  in  200  affections  of  single  valves,  the  aortic  was  involved 
in  over  40  instances,  or  20  per  cent. ;  while  the  mitral  was  affected 
m  157,  or  78.5  per  cent.  On  the  other  hand,  in  100  of  his  combined 
cases  the  incidence  on  the  aortic  was  88,  or  88  per  cent. ;  on  the 
mitral  98,  or  98  per  cent.  So  far  as  my  own  statistics,  in  combined 
cases,  are  concerned,  they  tally  pretty  well  with  Sperling's.  In  44 
combined  cases  the  incidence  on  the  aortic  was  39,  or  86.8  per  cent. ; 
on  the  mitral  40,  or  90  per  cent.  From  these  statements  it  appears, 
therefore,  that  mitral  disease  preponderates  in  frequency  over  aortic 
disease,  both  in  single  and  combined  cases. 

But  as  aortic  disease  is  apt  to  be  a  rather  late  phenomenon  in 
general  endocarditis,  which  attacks  the  mitral  first,  as  a  rule,  we 
look  for  implication  of  the  aortic  in  advanced  mitral  disease.  In 
my  44  cases  this  conjunction  occurred  in  37,  or  84  per  cent.  If 
the  tricuspid  is  involved,  it  is  apt  to  be  still  later  in  the  endocardial 
cycle. 

Aortic  disease  gives  rise  to  both  insufficiency  and  obstruction, 
the  latter  often  erroneously  regarded  as  synonymous  with  stenosis. 
For  obstruction  may  exist  without  stenosis,  as  shown  in  Case  XVII. 
Insufficiency  is  the  more  common. 

Insufficiency  of  the  aortic  was  first  noted,  it  is  said,  by  Mor- 
gagni,  but  a  satisfactory  explanation  of  it  was  not  given  until  1830, 
when  Corrigan,  of  Dublin,  gave  his  masterly  description  of  it.  It 
is  more  frequent  in  males  than  in  females.  There  are  two  forms 
of  insufficiency,  (i)  organic  and  (2)  inorganic  or  relative,  each 
capable  of  giving  the  characteristic  signs  of  the  disease. 

Of  the  organic  variety  one  of  the  prominent  causes  that  has 
been  given  is  congenital  malformation,  but  judging  from  my  ex- 
perience this  condition  must  be  extremely  rare.  In  the  congenital 
cases  that  I  have  seen,  closure  of  the  valves  was  usually  perfect,  not- 
withstanding their  defective  construction.  Furthermore,  the  claim 
made  that  congenital  malformation  is  an  etiological  factor  is  apt  to 


68  Diseases  of  the  Aortic  Valve 

he  associated  with  the  statement  lliat  the  Icatlets  had  undergone 
inflammatory  changes.  But  these  changes  ma\  have  occurred  in- 
dependently of  the  anomalies.  In  fact,  there  is  no  reason  why  mal- 
formed segnients  should  incite  cither  inflammatory  or  degenerative 
changes.  In  this  connection  it  nia\  be  said  that  the  small  fenestra- 
tions so  commonly  seen  in  the  leaflets  do  not  produce  insufiiciency, 
though  large  ones,  the  result  of  rupture,  may  do  so. 

A  more  common  cause  is  endocarditis,  which  may  be  of  the 
benign  or  malignant  variety.  The  latter,  due  to  acute  infective 
processes  such  as  gonorrhoea,  etc.,  is  usually  fatal,  but  the  former, 
which  is  more  common  and  usually  the  result  of  rheumatism  or  the 
continued  fevers,  is  a  slow,  subacute  process,  originating  with  vege- 
tations on  the  valves,  which  either  grow  into  tuberous  masses  that 
v/ill  eventually  snap  off,  or  undergo  fatt}-  degeneration,  or  harden 
down  into  calcareous  nodules  causing  obstruction.  Again,  adhesions 
may  take  place  between  the  cusps,  or  between  the  cusps  and  the 
adjacent  walls.  In  one  of  my  cases  a  calcareous  body  was  found 
attached  to  the  edge  of  a  leaflet,  and  it  must  have  been  carried  back- 
ward and  forw^ard  in  the  blood  current.  In  another  a  tumor  the 
size  of  a  chestnut  lay  beneath  one  of  the  leaflets,  preventing  its 
closure, 

A  cause  often  assigned  is  arteriosclerosis,  and  it  is  the  most 
serious.  Occurring  in  early  middle  or  advanced  life,  it  is  a  general 
systemic  disturbance  implicating  other  important  organs,  and  in- 
deed the  whole  arterial  system.  At  first  it  is  merely  a  slow  scle- 
rotic change,  but  with  advancing  age  and  under  certain  conditions 
it  assumes  a  degenerative  character,  from  which  there  is  little  hope 
of  amelioration,  but  only  a  prospect  of  progressive  destruction. 

The  first  of  the  causes  of  arterio-sclerosis  is  to  be  found  in  the 
strain  or  tension  of  severe  exercise.  This  condition  is  met  with  not 
only  in  the  toiler  (laboring  man),  but  also  in  the  athletes  training  for 
feats  of  strength  or  endurance.  Alcohol  is  another  of  the  causes. 
A  third  is  syphilis,  which  produces  at  first  hyaline  changes  in  the 
vascular  tunics  and  then  thickening  of  the  walls.  Another  cause 
is  lithaemia,  which  produces  changes  in  the  vessels  somewhat  simi- 
lar to  those  resulting  from  syphilis.  Rupture  of  a  valve  is  another. 
This  is  a  rarity,  but  I  have  seen  it  at  post-mortems.  It  may  occur 
in  health  as  the  result  of  a  fall  or  severe  concussion ;  but  a  slight 
accident,  such  as  a  hurried  walk,  may  produce  it,  when  the  valve  is 
infiltrated  and  brittle. 

Relative  insiifUciency  is  of  comparatively  infrequent  occurrence. 


Diseases  of  the  Aortic  Valve  69 

It  may  occur  in  any  form  of  hy])crtrophy  of  the  left  ventricle,  but 
is  unusual,  unless  associated  either  with  a  sacculated  aneurism  of 
the  arch,  or  the  fusiform  dilatation  sometimes  found  in  its  ascend- 
ing portion  (Hodgson's  disease).  This  form  of  insufficiency,  there- 
fore, is  of  late  occurrence  in  life,  while  organic  insufficiency  may 
occur  at  any  time. 

In  the  endocardial  forms  occur  the  usual  indications  of  that 
flisease,  which  do  not  differ  materially  from  the  endocardial  lesions 
of  other  valves ;  though  the  intense  rigidity  that  is  seen  in  the 
mitral  and  the  infiltration  of  the  adjacent  parts  is  not  so  common. 
But  a  very  small  amount  of  valvular  infiltration  may  produce  in- 
sufficiency, by  shortening  the  cusps.  In  fact,  there  may  be  great 
relaxation  of  the  ling  at  the  base  of  the  valves.  This  is  seen  in 
the  relative  insufficiency  that  is  apt  to  attend  the  dilatation  of  the 
aorta  from  either  the  fusiform  or  sacculated  aneurism. 

In  arterio-sclerosis,  which  is  in  most  cases  associated  with  endo- 
carditis, there  may  be  deposits  at  the  base  of  the  valves  without  in- 
sufficiency; or  a  spiculum  or  plate  projecting  out  may  cause  insuf- 
ficiency, so  that  a  considerable  amount  of  arterio-sclerosis  may  exist 
without  insufficiency.  As  in  endocarditis,  it  is  the  location  and 
configuration  of  the  deposit  rather  than  its  size  which  determines 
the  insufficiency.  There  are  great  differences  in  its  degree.  In 
moderate  cases  there  may  be  only  a  triangular  defect ;  in  advanced 
instances  it  may  take  the  form  of  a  slit  or  cleft.  Occasionally  the 
opening  may  be  widely  dilated  ;  but  there  may  be  an  enlargement  of 
the  leaflets  to  compensate  for  the  widened  opening. 

In  aortic  insufficiency  the  changes  in  the  heart,  in  the  progressive 
evolution  of  insufficiency,  are  as  follows  in  an  uncomplicated  case : 
Owing  to  the  leak  in  the  aortic  valve  some  of  the  blood  in  the  aorta 
regurgitates  during  diastole  into  the  left  ventricle,  and  meeting 
there  the  normal  quantum  of  blood  coming  at  the  same  time  from 
the  left  auricle,  causes  dilatation  of  the  ventricle.  The  latter,  in 
order  to  expel  this  increased  amount  of  blood,  hypertrophies.  Now 
if  the  insufficiency  is  progressive,  or  if  stenosis  is  combined  with 
insufficiency,  there  will  be  a  progressive  increase  of  blood  in  the 
left  ventricle.  But  the  increased  collection  of  blood  in  the  left 
ventricle  will  embarrass  the  left  auricle,  and  through  it  the  current 
of  blood  flowing  into  it  from  the  lungs  will  be  delayed,  so  that  the 
right  ventricle  will  also  dilate  and  hypertrophy.  But  even  if  the 
right  ventricle  should  enlarge  when  a  sudden  call  is  made  on  the 
heart,   it   may   diminish   in   size   w^hen   the   strain   has   been   taken 


yo  Diseases  of  the  Aortic  Valve 

off.  Hence  the  enlargement  of  the  left  rather  than  the  right 
heart  is  a  measure  of  the  success  of  compensation.  This  aortic 
lesion  makes  the  big  and  Icvig  heart  where  dilatation  and  hypertro- 
phy are  very  prominent.  In  one  of  my  cases  with  obstruction  and 
marked  insufficiency  the  heart  weighed  29  ounces. 

The  early  development  of  aortic  insufficiency  is  so  insidious 
that  it  is  apt  to  be  overlooked.  Indeed,  at  first  no  physical  signs 
may  be  present,  and  the  attention  of  the  patient  is  first  called  to  it 
b\-  subjunctive  symptoms,  such  as  precordial  oppression,  palpitation, 
fulness,  roaring  in  the  head,  sparks  before  the  eyes  (denoting  an 
irregular  supply  of  blood  to  the  head),  or  anginoid  attacks.  Occa- 
sionally these  symptoms  are  only  evoked  by  a  strain  or  excitement 
of  some  kind,  or  when  the  hypertrophy  does  not  keep  pace  with  the 
growing  insufficiency. 

If  arterio-sclerosis  is  at  fault,  there  may  be  the  fades  arterio- 
sclcrolica.  In  endocardial  cases,  however,  the  face  is  often  pale, 
In  arterio-sclerosis  there  will  also  be  general  systemic  changes,  and 
it  is  in  these  cases  particularly  that  there  is  apt  to  be  pain. 

On  inspection  in  well  established  cases  there  is  a  broad  area  of 
cardiac  pulsation.  In  children  and  young  people  there  may  be  a 
bulging  of  the  praecordium,  and  occasionally  systolic  contraction 
of  the  soft  parts  owing  to  the  flexibility  of  the  walls  of  the  chest 
and  the  pressure  of  the  enlarged  heart,  which  often  displaces  the 
lungs. 

The  apex  may  be  found  in  the  7th  or  8th  space  instead  of  the 
5th,  and  may  extend  to  the  line  of  the  nipple,  or  in  very  rare  cases 
to  the  axilla.  In  well  developed  cases  the  impulse  will  be  strong 
and  heaving.  Sometimes  there  is  a  thrill  when  obstruction  is  pres- 
ent ;  it  may  be  systolic  or  diastolic. 

Percussion  will  demonstrate  that  this  is  the  large  and  long  heart, 
and  as  dilatation  and  hypertrophy  are  largely  confined  to  the  left 
ventricle,  the  heart  will  assume  a  more  vertical  position  than  usual. 
But  during  the  temporary  dilatation  and  hypertrophy  of  tbe  right 
ventricle,  that  may  occur  before  compensation  is  established,  after 
excitement  or  strain,  or  in  failing  compensation,  the  dulness  may 
extend  an  inch  or  more  beyond  the  right  margin  of  the  sternum. 

On  auscultation  a  prolonged  murmur  is  heard  in  diastole  over  the 
aortic  area,  w-hich  corresponds  to  the  second  right  or  left  inter- 
space and  intermediate  space,  and  the  bruit  is  propagated  down 
towards  the  ensiform  cartilage,  but  it  is  usually  heard  with  greatest 
intensity  in  the  middle  sternal  region,  extending  sometimes  to  the 


Diseases  of  the  Aortic  Valve  71 

right,  but  ordinarily  to  the  left,  of  the  sternum.  Occasionally  it  is 
continued  to  the  apex  and  even  beyond  it,  the  "Flint  murmur." 
Indeed,  it  may  closely  simulate  the  murmur  of  mitral  obstruction 
and  be  produced  by  the  blood  impinging  on  a  leaflet  of  the  stiffened 
mitral,  for  in  more  than  half  the  cases  aortic  insufficiency  is  com- 
bined with  mitral  disease.  In  dilatation  of  the  ascending  arch  of 
the  aorta  (or  Hodgson's  disease),  which  is  common  in  advanced  ar- 
terio-sclerosis,  the  murnmr  may  be  carried  far  to  the  right,  but  the 
dilated  arch  will  not  necessarily  be  dull  on  percussion.  The  mur- 
mur may  occur  at  any  part  of  the  diastole,  and  may  entirely  super- 
sede the  second  sound. 

The  bruit  is  often  described  as  "gushing,"  "swishing"  or  "whir- 
ling," but  it  may  be  so  faint  as  to  be  overlooked.  It  may  also  be 
rough,  or  even  musical.  The  intensity  of  the  bruit  depends  on  the 
size  of  the  opening,  and  the  force  of  the  contraction  of  the  ventri- 
cle. When  extreme  stenosis  exists  or  in  extreme  dilatation  there 
may  be  no  murmurs.  Other  lesions  of  the  valves  may  also  mask 
them. 

The  piilse  is  large  and  quick  because  the  arteries  are  dilated 
by  the  powerful  cardiac  impulse,  which  has  to  be  short  in  point  of 
time  to  drive  the  requisite  quantity  of  blood,  during  the  interval 
allowed  it.  But  this  quick  discharge  of  blood  at  the  aortic  is  fol- 
lowed by  a  sudden  leak  or  backward  regurgitation  into  the  ventri- 
cle. Hence  the  characteristic  pulse  first  described  by  Corrigan  in 
1830  and  known  as  the  "cannon  hall,"  "pistol  shot,"  "trip  havuner," 
"water  hammer,"  or  "Corrigan."  It  was  for  a  time  thought  that 
the  sphygmograph  alone  could  furnish  a  ready  diagnosis  of  this 
condition,  but  it  is  now  known  not  to  be  pathognomonic,  for  a  similar 
pulse  has  been  occasionally  found  in  aneurism  and  anaemia. 

Another  sign  is  the  capillary  pulse.  Rub  the  patient's  fore- 
head with  a  towel  until  it  is  red  and  then  note  how  the  systolic 
action  of  the  heart  increases  the  ordinary  redness,  especialh-  at  the 
border  of  the  reddened  area.  This  capillary  pulse,  however,  due 
to  the  left  ventricle's  forcing  a  column  of  blood  directly  into  the 
capillaries,  is  seen  in  all  hypertrophied  hearts.  Nor  is  the  venous 
pulse  of  Quincke  pathognomonic.  It  merely  indicates  that  the  blood 
is  forced  through  the  capillaries  into  the  veins. 

In  aortic  insufficiency  there  is  apt  to  be  visible  pulsation  of  the 
arteries.  There  is  also  pulsation  of  the  jugulars  when  compensa- 
tion is  incomplete. 

Pressure  with  the  stethoscope  on  the   femoral   will   sometimes 


72  Diseases  of  the  Aortic  Valve 

produce  a  short  systolic  sound  ("f^istol-shot").  Such  pressure  in 
health  will  produce  a  systolic  murmur,  but  if  a  diastolic  is  also  pro- 
ducetl  {Diirocicz's  sign)  it  is  a  pretty  sure  sign  of  aortic  regurgita- 
tion.     Still  it  is  not  often  met  with. 

Attacks  of  angina  are  more  frequent  in  aortic  insufficiency  than 
in  any  other  valvular  lesion.  The  other  symptoms  often  noted 
are  headache,  dizziness,  palpitation,  thrill,  and  pain  transmitted  up 
the  neck  and  down  the  arm.  S  ltd  dot  death  is  more  frequent  in 
this  lesion  than  in  any  other  form  of  valve  disease ;  and  it  is  here 
that  neurotic  disturbances  are  so  prominent.  In  fact,  such  dis- 
turbances should  be  expected,  though  they  may  be  merely  of  the 
hysterical  variety.  As  in  all  other  forms  of  valvular  and  non-valvu- 
lar disease,  there  are  three  stages. 

During  the  first  stage,  in  organic  cases,  as  the  dilatation  and  hy- 
pertrophy of  the  heart  keep  pace  with  the  advance  of  the  insuf- 
.Hciency.  there  may  be  no  subjective  symptoms,  unless  the  patient 
imdergoes  emotional  excitement,  or  strains  his  heart  in  some  way. 
Then  the  hypertrophied  heart  finds  itself  unable  to  cope  with  the 
increased  load,  and  the  lungs  fill  up  with  blood,  causing  dyspnoea 
and  palpitation  ;  and  such  attacks  are  always  liable  to  occur. 

In  tlie  second  stage  compensation  will  have  been  established, 
and.  barring  such  incidents  as  have  just  been  described,  there  will  be 
no  subjective  signs.  This  stage  may  last  many  years,  fifteen  or 
twenty,  perhaps  more. 

When  compensation  is  about  to  fail,  its  approach  will  be  her- 
alded by  shortness  of  breath  and  dyspnoea,  especially  at  night, 
cough  and  acceleration  of  the  pulse.  The  pulse  will  be  rapid,  no 
to  I20.  or  more.  A  new  sign  is  at  hand  as  soon  as  the  systemic  cir- 
culation is  involved:  we  now  note  pulsation  in  the  epigastrium,  due 
to  dilatation  of  the  vessels  in  the  liver. 

Aortic  insufficiency  is  recognized  with  comparative  ease.  In  my 
37  cases  it  was  noted  in  23,  or  62  per  cent.  In  65  proved  by  post- 
mortems at  the  Massachusetts  General  Hospital,  only  44  \vere  rec- 
ognized, or  67  per  cent.  The  diagnosis  is  based  on  five  principal 
points. 

We  have  the  large  and  long  heart,  because  in  it  dilatation  and 
hypertrophy  are  prominent,  but  the  dilatation  and  hypertrophy  are 
mainly  confined  to  the  left  ventricle.  The  position  of  the  heart 
is  apt  to  be  somewhat  vertical. 

In  consequence  of  the  enlargement  of  the  left  ventricle  this 
displaces  or  compresses  the  lungs,  so  that  it  comes  nearer  to  the 


Diseases  of  the  Aortic  Valve  73 

sternum  than  usual,  and  its  pulsation  is  better  communicated.  For 
the  same  reason  the  beat  is  more  diffuse  anrl  heaving. 

The  murmur  is  usually  soft,  but  not  neces.sarily  so ;  it  may  be 
rouo;h  or  musical,  while  it  is  conveyed  downwarrl,  and  is  apt  to  be 
heard  best  in  the  mid-sternal  reg-ion  along  the  left  sternal  border ; 
occasionally  at  the  ensiform  cartilage  or  at  the  apex.  One  should 
not  pin  too  much  faith  on  the  murmur,  however,  for  it  may  be 
absent. 

The  pulse  is  usually  characteristic.  It  is  full  and  quick,  and  is 
apt  to  be  of  the  trip-hammer  variety. 

A  thrill  is  comparatively  rare,  but  it  may  occur  if  through  the 
distortion  of  a  valve  or  some  impediment,  the  current  of  blood  is 
twisted. 

In  general,  a  previous  history  of  alcoholism,  lead-poisoning  or 
syphilis  should  lead  to  a  suspicion  of  aortic  disease,  especially  in 
middle  life.  If  mitral  disease  has  been  previously  well  established, 
we  should,  in  70  per  cent,  of  the  cases,  expect  aortic  disease. 

One  of  the  greatest  difficulties  is  the  differential  diagnosis  be- 
tween aortic  valvular  disease  and  aortic  aneurism.  The  following 
diagnostic  points  must  be  taken  into  consideration : 

Aortic      insufficiency.       Bruit  Aneurism.      Bruit    and    thrill 

and    thrill    in    area    to    right   of  aflfect   both    arch   and   ventricle, 

sternum,    increasing   as    we   ap-  and  area  to  right  of  sternum,  di- 

proach  the  aorta  from  above.  minishing   as    we   approach   the 

No    dulness    necessarily    over  aortic  valve  from  above, 

dilated  aorta.  Dulness    widespread    if   aneu- 

May    also    be    inequality    of  rismal  sac  contains  fibrin.     Ine- 

radial  pulse,  but  "trip-hammer"  quality     of     radial     pulses,     but 

variety  the  rule.  never  the  "trip-hammer."  Syph- 

In  arterio-sclerosis  may  be  a  ilitic  history  usually.       The  X- 

history     of     syphilis.      May    be  ray  throws  a  shadow  correspond- 

caused  also  by  rheumatism,  gout,  ing  to  the  sac. 
lead    poisoning    and    infections. 
The  X-ray  throws  no  shadow. 

In  general,  the  amount  of  the  lesion  is  proportioned  to  the  hyper- 
troph}-  of  the  heart,  except  when  obesity  or  Bright's  disease  co- 
exist. The  prognosis  depends  on  many  considerations.  If  the 
insufificiency  is  of  traumatic  origin,  such  for  example  as  is  caused  by 
a  sudden  strain,  the  prognosis  may  be  good,  but  such  accidents  are 
extremely  rare.    Occurring:  in  the  voung.  before  the  usual  degenera- 


74  Diseases  of  the  Aortic  Valve 

tive  changes  liavc  taken  place,  it  lias  a  better  outlook.  It  is  also 
comparatively  favorable,  because  compensation  is  established 
by  the  left  ventricle,  which  alone  is  competent  to  rectify  the 
bad  effects  of  this  lesion.  But  though  compensation  may  last  fifteen 
to  twenty  years  or  more,  long  life  is  seldom  attained.  In  the  man- 
ageinent  of  a  case  we  should  remember  that  compensation  depends 
on  the  ability  of  the  left  ventricle  to  do  its  work.  Hence  its  dilata- 
tion and  hypertrophy  are  to  be  maintained.  Whenever  it  shows 
signs  of  irregular  action  or  feebleness,  it  should  be  quieted  and  sus- 
tained. Rest  in  the  recumbent  position  is  at  first  the  sine  qua  non 
in  an  acute  attack,  while  cold  compresses  may  be  applied  to  the  chest, 
and  the  extremities  massaged,  so  as  to  draw  off  as  much  blood  as 
possible  from  the  heart.  T  am  in  the  habit  of  using  in  these  cases 
the  bromides,  or  the  mono-bromate  of  camphor ;  sometimes  acet- 
analid  in  2  to  5  grain  doses ;  also  Hoffman's  ether  and  the  comp. 
tincture  of  valerian  in  drachm  doses.  When  the  acute  stage  is  over 
1  use  carbonated  baths  and  exercises. 

The  following  cases  taken  from  my  hospital  records  illustrate 
some  of  the  ordinary  varieties  of  aortic  insufficiency : 

Case  XIII.     Malignant  Endocarditis;  Aortic   Insufficiency  and 

Obstruction. —  ,   fifty-six,   single,   was   admitted   to   hospital 

May  2ist,  1881.  Patient  had  been  a  well  man,  according  to  his 
statements,  up  to  four  weeks  before  admission.  At  that  time  he  was 
attacked  with  pain  in  all  his  joints,  which  were  swollen  and  disabled. 
For  the  previous  three  weeks  he  had  suffered  from  headache,  epi- 
gastric distress,  and  nausea,  without  vomiting ;  and  during  this  time 
had  irregular  chills  and  sweats.  In  the  week  preceding  admission  he 
had  increased  dyspnoea,  but  without  cough. 

Physical  examination  showed  that  the  apex  was  in  the  fifth 
space,  one-half  an  inch  to  the  left  of  the  nipj)le.  A  double  mitral 
murmur  was  lieard.  Pulse  very  irregular.  Fine,  moist  rales  at  the 
bases  of  both  lungs.  Later  a  presystolic  murmur  was  heard  twice 
at  the  apex,  but  no  double  murmur.  Later  a  double  murmur  was 
heard  at  the  base.  Orthopnoea.  On  May  31st  signs  of  hypostatic 
congestion  were  recognized,  and  a  diagnosis  of  probable  ulcerative 
''malignant)  endocarditis  was  made.  The  patient  died  suddenly 
the  same  day. 

At  the  autopsy,  which,  unfortunately,  was  not  very  complete, 
it  was  found  that  the  pericardium  contained  half  an  ounce  of 
bloody  serum,  while  the  right  auricle  was  attached  posteriorly.  There 
was  a  large  vegetation  at  the  aortic  valve  and  an  ulcer  extended 


Diseases  of  the  Aortic  Valve  75 

beneath  the  valves,  from  the  aortic  to  the  mitral.  The  spleen  was 
irregularly  spotted  and  puckered  from  old  infarctions,  but  no  recent 
ones  were  found. 

Here,  then,  was  an  instance  of  aortic  insufficiency  in  an  old  be- 
nign endocarditis  which  had  taken  on  a  malignant  character. 

Case  XIV.  Organic  Aortic  Insufficiency,  with  Relative  Mitral  In- 
sufficiency.  ,  twenty-seven,  was  admitted  to  hospital  April  2, 

1887,  with  the  history  of  an  attack  of  acute  rheumatism  ten  years 
earlier,  and  a  recent  recurrence  one  week  before  admission.  On  phys- 
ical examination  a  low-tension  pulse  alternating  between  the  normal 
and  120  to  130  was  noted.  Apex  in  the  fifth  space.  Heart  enlarged. 
At  the  apex  there  was  a  soft  systolic  murmur  quite  diffused 
and  an  aortic  direct  and  indirect  murmur.  Dyspnoea,  palpitation  and 
nausea  followed  one  another  in  the  course  of  his  three  visits  to  the 
hospital.  During  the  last  of  these  he  developed  pleuris}'  with  effu- 
sion, and  thirty-two  ounces  of  fluid  were  withdrawn. 

The  apex  had  been  found  at  one  time  in  the  seventh  space. 
Heart  enlarged.  There  was  much  praecordial  pain  with  anginoid  at- 
tacks.     The  patient  died  Nov.  3rd,  1887,  with  acute  dilatation. 

At  the  autopsy  there  was  found  m.arked  aortic  insufficiency,  but 
it  was  not  thought  that  there  was  enough  infiltration  in  or  about  the 
valves  to  indicate  obstruction.  There  was  marked  mitral  insuf- 
ficiency without  organic  changes  (relative  variety).  Heart  weighed 
twenty-one  ounces.      Cardiac  tissues  degenerated. 

Case  XV.  Aortic  insufficiency,  zvith  Dilatation  of  the  Orifice 
and  Fusiform  Aneurism  of  the  Ascending  Arch  (Hodgson's  dis- 
ease).—  ,  sixty-four,  was  admitted  to  hospital  July  8th,  1882. 

Patient  admits  having  been  a  moderate  drinker,  and  having  had 
gonorrhoea  and  rheumatism.  On  admission  he  was  found  to  have 
cedema  of  the  upper  and  lower  extremities.  Double  aortic  murmur 
at  base.  Apex  in  fifth  space,  one-half  an  inch  outside  the  nipple. 
Rapid  and  irregular  pulse.  Patient  soon  developed  suppression  with 
albuminuria,  with  noisy  delirium  and  dyspnoea.  He  died  in  coma  on 
October  28th. 

At  the  autopsy  the  following  was  found:  Heart  not  markedly 
enlarged,  but  an  adherent  pericardium.  CaVities  dilated ;  all  valves 
sound  except  the  aortic.  The  aortic  segments  were  thickened  and 
shortened,  and  the  orifice  was  markedly  dilated.  The  ascending 
aorta  was  also  dilated  and  had  atheromatous  plaques,  ulcerations 
and  calcareous  deposits.  It  constituted  a  fusiform  aneurism  {Hodg- 
son's disease).      Kidneys   granular,   contracted   and   cystic.     Liver 


76  Diseases  of  the  Aortic  Valve 

slightly  cirrhotic  ;  chronic  meningitis.     Death  attributed  to  chronic 
diffuse  nephritis. 

Casf  Xl'I.  Relative  Aortic  and  Mitral  Insufficiency  Due  to  Car- 
diac Hypertrophy  of  Renal  Orii^i)i. —  ,  thirty-eight,  was  ad- 
mitted to  hospital  Aug.  22nd.  1887.  He  had  suffered  from  acute 
articular  rheumatism,  and  for  the  past  three  years  from  palpitation 
and  dyspnrea,  but  swelling  of  the  feet  and  abdomen  had  occurred, 
for  tlie  first  time,  about  a  week  previously.  On  admission  he  com- 
plained of  sparks  before  the  eyes,  cough  and  bloody  sputum  ;  was 
pale,  and  had  facial  oedema.  Pulse  irregular.  The  heart  w^as  found 
tc  be  hypertrophied.  Apex  one  inch  below  line  of  nipple  and  one 
and  one-half  inches  outside  it.  Double  aortic  and  also  a  mitral  re- 
gurgitant iTiurmur.  Urine  sp.  gr.  1012.  Trace  of  albumin.  The 
ursmic  symptoms  from  which  he  had  been  suffering  became  aggra- 
vated, and  he  died  about  two  weeks  after  admission. 

At  the  autopsy  it  was  found  that  so  far  as  the  aortic  and  mitral 
valves  were  concerned  there  was  no  organic  change,  except  a  slight 
roughness  in  the  aortic,  and  the  insufficiency  of  both  valves  was 
attributed  to  the  hypertrophy  of  the  heart  from  renal  implication. 

The  following  case  shows  incidentally  how  auscultatory  signs 
may  be  misinterpreted : 

Case  XVII.  Aortic  Insufficiency  mistaken  for  Mitral  InsufH- 
ciency. — B. —  was  admitted  to  hospital  December  nth,  1880.  The  pa- 
tient stated  that  he  felt  perfectly  well  up  to  three  weeks  previously, 
when  he  was  taken  with  pr?ecordial  distress  and  difficult  breathing. 
Two  weeks  later  he  had  cough  and  expectoration,  orthopncea,  general 
malaise,  nausea  and  vomiting.  On  examination  it  was  found  that  the 
heart  was  hypertrophied  and  that  there  was  pulsation  of  the  veins 
m  the  neck.  Apex  to  the  left  and  below  nipple.  Wavy  movement 
of  the  epigastrium.  Expiration  high  pitched  and  prolonged.  Con- 
solidation of  left  lung  posteriorly.  Murmur  at  apex  thought  to  be 
w'ith  first  sound.  Murmur  heard  behind  and  better  above  than  below 
the  scapula.  Diagnosis  of  dry  pleurisy  and  of  mitral  regurgitation. 
Patient  died  with  oedema  of  the  lungs  December  14th.  At  the  au- 
topsy both  lungs  were  found  to  be  almost  solid  at  their  bases.  The 
heart  was  enlarged.  Pulmonary  opening  dilated.  Dilatation  of 
right  heart.  Fresh  vegetations  on  border  of  aortic  valve.  Both 
cusps  thickened.      Obstruction,  but  no  stenosis.      Mitral  normal. 

In  the  absence  of  mitral  disease  we  see  in  this  case  how 
sometimes  the  murmur  of  aortic  insufficiency  may  be  conveyed  to 
the  apex  and  beyond,  probably  in  this  instance  through  the  agency 


Diseases  of  the  Aortic  Valve  TJ 

of  the  consolidated  left  lung,  the  result  being  an  error  in  the  diag- 
nosis. 

Aortic  Obstruction. — In  the  choice  between  the  words  obstruc- 
tion and  stenosis  I  select  the  former,  because  it  has  a  wider  signifi- 
cance, embracing  all  forms  of  stenosis,  wliile  the  latter  does  not 
embrace  all  forms  of  obstruction.  As  in  mitral  disease,  there  may 
be  obstruction  without  narrowing  (stenosis). 

Aortic  obstruction  is  a  tolerably  common  valvular  lesion.  Walshe 
put  it  second  in  his  list,  and  in  65  of  my  autopsies,  in  valvular  dis- 
eases, I  found  it  holding  the  same  position.  In  a  clinical  series  of 
50  cases,  however,  I  put  it  third.  But  while  there  is  a  general 
agreement  that  it  is  a  common  valvular  lesion,  it  is  not  so  well  un- 
derstood that  uncomplicated  aortic  obstruction  is  extremely  rare. 
Several  of  our  most  prominent  clinicians  have  seen  no  cases,  and  in 
the  pathological  records  of  the  Massachusetts  General  Hospital,  em- 
bracing 252  valvular  cases,  not  a  single  one  was  recorded.  In  my  65 
post-mortems  I  have  but  one.  If  there  were  any  lingering  doubt  as 
to  the  rarity  of  simple  obstruction,  a  search  through  the  literature 
should  dispel  it.  Certainly  painstaking  investigations  on  my  part 
have  discovered  only  a  very  few  published  cases  of  aortic  obstruction 
without  insufificiency.  It  well  might  happen  that  a  practitioner  with 
a  pretty  wide  experience  in  heart  cases  would  never  meet  wath  a  pure 
example  of  uncomplicated  aortic  obstruction. 

These  cases  will  be  referred  to,  however,  for  after  all  it  is  only 
from  uncomplicated  cases  that  we  can  frame  rules  for  diagnosis. 
Indeed,  the  inference  is  positive  that  heretofore  our  diagnoses 
have  for  the  most  part  been  based  on  phenomena  not  con- 
firmed by  autopsies,  or  on  cases  of  aortic  disease  complicated 
by  insufficiency.  But  while,  practically  speaking,  obstruction  is  usu- 
ally attended  by  insufficiency,  the  converse  is  not  true.  And  this  w^as 
shown  in  my  65  cases,  where  in  11,  or  17  per  cent.,  there  was  aortic 
insufficiency  without  stenosis  (obstruction),  but  of  course  relative 
insufficiencies   were   included. 

This  point  has  a  practical  bearing,  for  given  the  signs  of  aortic  ob- 
struction, and  the  chances  are  that  in  the  great  majority  of  instances 
obstruction  is  combined  with  insufficiency. 

These  two  forms  are  well  contrasted  in  the  following  cases : 

Case  XVIII.  Aortic  Obstruction  and  InsuMciency  Associated 
with  Aortic  Aneurism.  Syphilis. — J.,  thirty-eight,  painter,  was 
admitted  to  hospital  January  loth,  1883.  The  patient  had  contracted 
syphilis  about  seven  years  perviously,  secondary  manifestations,  such 


78  Diseases  of  the  Aortic  Valve 

as  sore  throat  and  alopecia,  occurring  four  or  live  years  later.  He 
then  complained  of  pain  in  the  sternum.  On  physical  examination 
direct  and  indirect  aortic  murmurs  were  distinctly  heard.  The 
patient  died  five  days  later,  during  a  sudden  attack  of  cyanosis  with 
dyspnoea. 

At  the  autopsy  the  pericardial  sac  was  found  to  contain  12  ounces 
of  serum.  The  heart  was  very  much  hypertrophied,  especially  the 
left  ventricle.  Weight  24  ounces.  The  aortic  valve  was  much 
thickened,  and  its  segments  were  shortened  by  atheromatous  deposits, 
there  being  insufficiency  and  obstruction.  All  the  valves  of  the  right 
side  were  normal. 

The  arch  of  the  aorta  was  the  seat  of  what  was  regarded  as  ex- 
tensive syphilitic  endarteritis,  with  ulcerations  and  cicatrices. 
At  one  point  to  the  right  of  the  aortic  valve  some  of  the  arterial 
coats  had  given  way  and  a  sacculated  aneurism  had  formed,  about 
the  size  of  a  hen's  egg.  A  small  opening  led  into  the  sac.  In  the 
liver  were  small  gummatous  tumors. 

Case  XIX.  Aortic  Stenosis  without  Insufficiency. — E.,  forty- 
eight,  was  admitted  to  hospital  April  4th,  1878.  The  patient,  whose 
only  previous  disease,  so  far  as  he  knew,  had  been  pneumonia,  or  pos- 
sibly scarlatina,  learned  that  he  had  heart  disease  one  year  previously 
from  a  physician  who  was  treating  him  for  a  cough  and  haemoptysis. 
Shortly  afterwards  he  found  that  his  lower  extremities  were  begin- 
ning to  swell.  Two  weeks  before  admission  the  oedema  had  reached 
his  scrotum,  and  the  urine  had  fallen  to  15  ounces  per 
day.  On  examination  the  apex  beat  was  found  to  be  diffused 
over  a  larger  area  than  normal  and  was  two  inches  below  the 
nipple.  On  auscultation  a  systolic  murmur  was  heard  at  the 
apex,  not  conveyed  to  the  left  or  behind  (tricuspid  regurgitation). 
At  the  base  w^as  a  double  murmur  supposed  to  be  an  aortic  direct 
and  indirect.  Pulmonary  oedema.  The  patient  was  put  under  active 
treatment,  with  digitalis  and  elaterium,  and  cupped ;  but  there  was 
little  reaction.  Symptoms  of  ursemia  supervened  and  he  died  twen- 
ty-four days  after  admission.  At  the  autopsy  his  heart  was  found 
tobe  very  large,  weighing  31  ounces.  All  cavities  distended.  Aortic 
perfectly  sufficient,  but  leaflets  contracted,  while  the  free  surface  ex- 
hibited a  small  row  of  white,  shining,  translucent  bodies.  Left  ventri- 
cle hypertrophied.  Right  very  little  hypertrophied.  Tricuspid  and 
pulmonary  insufficient,  a  large  stream  of  water  passing  through  the 
former.  Infarcts  in  both  kidneys.  Cysts  in  one.  Nutmeg  liver. 
Vessels  at  base  of  brain  atheromatous.    The  cause  of  death  in  this 


Diseases  of  the  Aortic  Valve  79 

case  was  uraemia,  induced  in  part  at  least  by  renal  embolism.  In  this 
case  the  only  error  committed  was  that  pulmonary  insufficiency  was 
mistaken  for  aortic  insufficiency.  The  extreme  rarity  of  the  former 
might  be  offered  as  an  excuse  for  the  failure  to  recognize  it. 

Aortic  obstruction  in  the  vast  majority  of  instances  is  caused 
by  arterio-sclerosis,  which  in  turn  often  means  syphilis,  and  it  is 
merely  an  extension  of  the  disease  of  the  aorta  back  into  the  valves, 
Or  rheumatism  may  cause  endocarditis,  which  invades  the  segments 
of  the  valves,  the  disease  beginning  at  the  free  edges,  generally  with 
the  development  of  vegetations  or  papillary  growths  and  a  contempo- 
raneous infiltration  of  the  segments,  and  subsequently  their  contrac- 
tion or  distortion.  Again,  the  leaflets  may  become  fused  together 
by  adhesive  inflammation,  leaving  a  triangular  or  funnel-shaped 
opening.  This  latter  is  not  so  common  as  in  mitral  stenosis.  In 
health  the  opening  should  admit  the  little  finger,  but  in  stenosis  it 
may  become  so  small  that  it  will  only  admit  a  small  sound,  or  even 
the  tip  of  a  slate  pencil,  as  in  one  reported  case. 

Congenital  aortic  obstruction,  which  is  a  true  stenosis,  is  only 
one  of  the  numerous  cardiac  anomalies,  the  combination  of  which, 
as  a  rule,  soon  ends  the  infant's  life.  Very  exceptionally,  patients 
may  live  with  aortic  stenosis  of  the  congenital  type  to  advanced  life, 
according  to  Eshner,^  who  has  reported  one  that  lived  to  the  age  of 
90  years.  The  duration  of  life,  however,  is  probably  measured  by  the 
insufficiency  that  accompanies  the  stenosis. 

Among  the  remoter  causes  are  strain  and  injury,  which  almost 
necessarily  lead  to  inflammation,  adhesion  and  contraction.  Other 
causes  of  obstruction  are  lateral  pressure  on  the  valves  by  something 
extra  cardiac,  as  an  enlarged  gland. 

Aortic  obstruction  being  a  late  event  in  valvular  disease,  it  is 
found,  as  a  rule,  after  middle  life ;  in  exceptional  cases  it  occurs  in 
early  life  or  even  in  infancy. 

The  obstruction  to  the  escaping  blood  throws  extra  work  on  the 
left  ventricle,  which  hypertrophies  and  dilates,  as  seen  in  Case  XIX, 
the  heart  becoming  greatly  enlarged.  It  has  been  claimed  (Whit- 
taker)  that  it  never  assumes  the  magnitude  of  the  heart  in  aortic 
insufficiency,  but  this  is  disproved  by  Case  XIX,  where  the  heart 
weighed  31  ounces,  and  this  also  disproves  the  statement  of  Potain 
that  a  scarcely  appreciable  hypertrophy  with  but  slight  displacement 
of  the  apex  speaks  for  aortic  (stenosis)  obstruction,  for  the  case 
given  was  one  of  pure  aortic  stenosis.  The  truth  is  that  while  the 
left  heart  hypertrophies  invariably  from  a  moderate  degree  to  an 


8o  Diseases  of  the  Aortic  Valve 

enormous  extent,  it  does  not  on  the  whole  average  so  much  as  in 
aortic  insufficiency. 

Basing  tiie  symptoms  of  uncomplicated  aortic  obstruction  on 
tlie  recorded  cases*  I  have  collected,  including  one  of  my  own,  I  find 
the  following  symptoms : 

Thev  are  mostly  in  males,  usually  after  middle  life,  though  one 
of  them  was  19  years  of  age.  The  pulse  is  slow  and  weak,  some- 
times irregular.  Dyspncea,  palpitation  and  syncopal  attacks  occur. 
The  impulse  is  diffused  over  a  wide  area  and  the  apex  is  to  the 
left.  Usually  the  murmur  is  absent ;  always  when  stenosis  is  ex- 
treme. In  two  cases,  systolic  murmurs  at  the  apex,  or  thereabouts, 
were  attributable  to  tricuspid  regurgitation. 

Among  other  signs  are  pulsation  of  the  veins  in  the  neck  and 
in  the  interclavicular  notch,  cyanosis  and  dropsy.  There  was  no 
thrill  in  any  of  the  cases.  Right  ventricle  moderately  or  greatly 
enlarged ;  left  less  so.     Embolism  and  oedema  are  other  features. 

It  will  be  noted  (from  the  above  summary)  that  no  thrill  was 
found,  and  this  may  be  regarded  as  an  important  negative  sign.  We 
have  seen  that  it  is  a  positive  sign  in  insufficiency.  The  impulse,  of 
course,  varies  with  the  stage  of  the  disease.  It  is  diffuse,  though 
not  so  strong  and  heaving  as  in  insufficiency  combined  with  steno- 
sis. The  murmur  is  usually  heard  best  in  the  second  or  third  right 
intercostal  space,  is  long-drawn,  conveyed  up  the  great  vessels 
of  the  neck,  and  gradually  diminishes  in  loudness  as  it  asscends.  Its 
quality  depends  on  the  character  of  the  obstruction.  If  the  orifice 
is  smooth  or  small,  there  may  be  no  murmur.  A  systolic  murmur  at 
the  apex,  due.  according  to  Dickinson,  to  regurgitation  from  strong 
pressure  through  the  mitral,  w^as  attributable  according  to  Case  XIX 
to  tricuspid  regurgitation.  When  there  is  a  rough  or  musical  mur- 
mur, there  is  roughness  in  the  valve  or  just  above  it.  It  may  be  so 
loud  that  it  is  heard  all  over  the  heart,  and  cannot  well  be  located. 
The  apex  will  be  low  down  to  the  left,  and  may  even  reach  the  sev- 
enth space,  and  extend  two  inches  outside  the  nipple,  but  this  is  ex- 
ceptional. In  all  cases  there  will  be  an  enlarged  heart  with  the  apex 
carried  downwards  and  to  the  left.  There  must  be,  in  the  early  and 
middle  stages,  certainly  until  the  orifice  has  diminished  to  a  mere 


^  Farwell,  Birmingham  Med.  Gac,  1830. 
Eshner,  Path.  Soc.  of  Phil.,  XIV..  p.  154. 
Ashton,  Path.  Soc.  of  Phil.,  XVII..  p.  103. 
Gibbons,  Path.  Soc.  of  Phil..  XVII.,  p.  134. 
Murray.  Path.  Soc.  of  London,  XXL,  p.  98. 
Owen,  Path.  Soc.  of  London,  XXXIII. ,  p.  72. 


Diseases  of  the  Aortic  Valve  8l 

slit,  a  systolic  bruit,  heard  best  in  the  aortic  area  and  carried  up 
through  the  great  vessels  of  the  neck.  When  stenosis  and  insuf- 
ficiency are  combined,  as  is  usual,  there  will  be  the  signs  of  insuffic- 
iency. Engorgement  of  the  lungs  due  to  commencing  heart  fail- 
ure will  lead  to  tricuspid  regurgitation,  and  will  be  evidenced  by  a. 
systolic  murmur  near  the  apex,  increasing  as  the  ear  nears  the  ensi- 
form  cartilage.  Obstruction  of  the  pulmonary  artery  is  rare,  but  it. 
may  lead  to  confusion,  because  the  signs  of  aortic  obstruction  are 
sometimes  best  heard  over  the  pulmonary  valve.  In  pulmonary  valve 
disease,  however,  the  sounds  are  very  superficial. 

Angina,  embolism  and  vertigo  are  especially  common  in  aortic 
stenosis. 

Owing  to  the  diversity  of  causes,  the  prognosis  is  variable.  In; 
congenital  cases  aortic  stenosis  is  usually  only  one  of  the  many  car- 
diac anomalies  which  together  soon  end  the  infant's  life ;  so  that  the: 
consideration  of  this  matter  from  the  standpoint  of  the  aortic  lesioni 
is  of  comparatively  little  importance.  And  yet  a  man  with  acquired 
stenosis  of  an  extreme  type  may  live  to  ninety,  as  in  Eshner's  case. 
Considerable  contraction  of  the  orifice  ma}'  exist  for  a  long  time,  if 
hypertrophy  develops  contemporaneously  with  the  construction ; 
but  unfortunately,  as  already  said,  we  seldom  have  pure  cases  of 
aortic  disease.  As  it  is  generally  combined  with  aortic  insuf- 
cicncy,  the  duration  of  life  must  be  measured  by  the  insufficiency^ 
and  the  rule  laid  down  by  Fagge  is  probably  correct  that  in  the  see^ 
saiv  of  aortic  disease  the  louder  the  first  sound  the  better  the  prog-- 
nosis ;  the  louder  the  second  sound,  the  reverse.  But  a  short  sec- 
ond sound  is  regarded  as  more  unfavorable  than  a  long-drawn  sec- 
ond sound.  When  there  is  a  loud  systolic  murmur  the  probability 
IS  that  there  is  a  wide  opening  and  little  obstruction.  If  the  patient 
has  syphilis  the  prognosis,  other  things  being  equal,  is  worse  than 
if  he  has  rheumatism.  And  yet  if  he  is  under  good  management,  and 
leads  a  careful  life,  it  is  better  than  in  rheumatism.  Unfortunately 
we  are  too  apt  to  believe  that  a  prolonged  course  of  treatment  ex- 
tending over  two  or  three  years,  by  mercurials  and  the  iodides,  will 
rid  the  system  permanently  of  the  poison.  This  is  a  very  serious 
error. 


ClIAl'TER  \'II. 

PULMOXARV  \AL\E  AFFECTIONS.^ 

Of  all  cartliac  vahcs  ihc  pulnioiiary  is  least  often  affected.  Very 
exceptionally  it  is  a  single  lesion.  Sperling  {Cibson's  Dis.  of  the 
Heart,  London.  1898).  with  his  large  experience,  has  not  recorded 
ii  single  case.      Fortunatcl}   I  have  brief  notes  of  one. 

In  association  with  other  valvnlar  diseases,  pulmonary  affec- 
tions occur  in  the  ratio  of  1  to  al)(>ut  10  per  cent.  Si)erling  puts  it 
at  4  per  cent.  Insufficiencx  is  the  form  commonh-  seen  in  adult  life; 
stenosis  in  foetal  life  or  infancy. 

Pulmonary  valve  diseases  occurring  in  adult  life,  however,  are 
usually  consecutive  to  endocarditis  or  other  valves,  or  to  arterio- 
sclerosis, the  ratio  being,  according  to  m\-  tables,  six  in  a  total  of 
177  lesions  verified  by  post-mortems.  In  my  office  cases  the  ratio 
v.as  put  at  3  per  cent.,  and  in  fifty  taken  from  my  clinic  by  myself 
and  assistants,  pulmonary  insufficiency  was  at  the  bottom  of  the 
list.  Walshe  {Dis.  of  the  Heart,  London,  1873,  p.  105)  from  his 
list  makes  it  occupy  the  sixth  place  in  a  total  of  seven  varieties  of 
lesions.  But  his  clinical  notes,  not  to  any  large  extent  confirmed 
by  pathological  data,  are  interesting  rather  than  convincing.  Five 
of  the  cases  I  now  record  are  taken  from  my  post-mortem  records 
as  former  pathologist  to  the  St.  Luke's  and  Presbyterian  hospitals. 
<Dne  was  furnished  me  by  the  Babies'  Hospital.  Temporary  insuffi- 
ciency is  doubtless  of  common  occurrence.  For  a  slight  diastolic 
murmur  can  be  produced  over  the  second  or  third  left  intercostal 
space,  after  the  breath  has  been  held  for  a  brief  space,  when  respira- 
tion is  again  commenced.  Chronic  insufficiency,  however,  is  not 
common.  Gerhardt,  in  "iSqo, '(Ciiaritc  Aiiiia/cn,  XX'TT,  s.  255)  had 
collected  only  twenty-nine  cases  that  were  verified  by  post-mortems, 
and  Barie  a  year  later  (Arch.  Gcii.  de  Paris,  1891,  Vol  T,  p.  650, 
and  Vol.  H.  p.  30  and  183)  fifty-eight,  similarly  supported  by  post- 
mortems from  the  years  183 1  to  1874.  Pitt,  however,  has  carried 
the  number  up  to  ninety-nine-  (Albiitt's  System  1899),  while,  as 
already  said,  I  have  been  able  to  add  six  new  cases,  brief  notes  of 
which  T  [rive : 


'  Published  ririginally  in  the  Med  Ncivs,  Sept.  6,  IQ02. 

'Of  these  forty-four  were  taken   from  the  pathological   records  of  Guy's 
Hospital.  , 


Pulmonary  Valve   Affections  ^53 

Case  XX.  Phthisis;  fatty  heart,  chronic  parenchymatous  nephri- 
tis; tricuspid  and  pulmonary  insufficiency  {relative). — A  woman  of 
forty-two  years  was  admitted  to  hospital  January  23,  1884,  with  the 
usual  signs  of  tuberculous  phthisis,  including  cough,  dyspncjea,  pro- 
fuse greenish-yellow  sputum,  night  sweats  and  cyanosis.  The  pulse 
reached  104;  temperature  102°  h".  She  died  of  heart  failure  about 
two  weeks  after  admission.  At  the  autopsy  all  the  heart  cavities  were 
found  dilated,  the  walls  thinned  and  apparentl}-  fatty.  The  aortic 
and  mitral  valves  were  sufficient,  the  tricuspid  markedly  insufficient, 
the  pulmonary  less  so.  The  cause  of  death  was  put  down  to  fatty 
heart  and  chronic  parenchymatous  nephritis.  Tlie  tricuspid  and  pul- 
monary insufficiencies  were  due  to  the  dilated  right  heart,  such  as 
occurs  in  the  fatty  heart  of  phthisis.  The  attention  of  the  physicians 
appears  to  have  been  directed  to  the  lungs  chiefly,  so  that  the  lesions 
of  the  right  heart  escaped  notice,  as  very  frequently  happens  under 
such  circumstances. 

Case  XXI.  Aortic  and  nntral  endocarditis;  tricuspid  and  pul- 
monary insufficiency  {relative). — A  widow  of  forty-eight  years  was 
admitted  to  hospital  June  27,  1885.  The  patient  had  enjoyed  fair 
health  until  three  months  previously,  when  she  was  taken  with 
cough,  dyspnoea  and  night  sweats.  On  examination  the  apex  was 
found  in  the  sixth  space,  43/^  inches  from  the  median  line.  Loud 
systolic  murmur  at  the  apex,  conveyed  to  the  left,  and  even  to  the 
angle  of  the  scapula.  A  loud  systolic  murmur  heard  over  the  sec- 
ond and  third  right  interspaces,  propagated  up  the  great  vessels. 
No  aortic  diastolic  murmur  appreciable.  Pulse  128,  irregular  in 
force  and  frequency.  Later,  some  enlargement  of  liver.  Mental  dis- 
turbance. Anteriorly,  respiratory  murmur  rough ;  sibilant  and 
sonorous  rales.  Still  later,  ascites  developed.  The  patient  died  of 
heart  failure.  At  the  post-mortem  examination  the  heart  was  found 
enlarged,  weighing  eighteen  ounces.  Cavities  dilated.  \"egetations 
at  aortic  and  mitral,  causing  obstruction  at  both  orifices.  Pulmon- 
ary and  tricuspid  valves  insufficient  from  dilatation  of  the  right  ven- 
tricle. The  pulmonary  and  tricuspid  insufficiencies  were  not  recog- 
nized during  life. 

Case  XXII.  Arteriosclerosis:  tricuspid  iusufHcicncx  and  rela- 
tive pulmonary  insufficiency,  due  to  dilatati'^n  of  the  pul- 
monary artery;  Hodgson's  Disease. — A  sailor  of  fiftv-six 
years  was  admitted  to  hospital  November  27,.  1886,  for 
cough,  dyspnoea  and  bloody  expectoration,  which  had  per 
sisted    for   a   month.     Syphilitic   history   of   thirtv   years"  standing. 


84  Pulmonary   Valve   Affections 

On  examination  he  was  found  to  have  general  cedcnia  and  em- 
physema. \'isible  pulsations  in  brachial,  radial  and  ulnar  arteries ; 
venous  pulsation  in  jugular  veins.  Urine  sp.  gr.  1002;  albumin 
33  per  cent.  Granular  and  hyaline  casts.  Fairly  loud  systolic  mur- 
nnir  heard  over  the  liver  and  at  lower  end  of  sternum.  Diagnosis 
of  tricu.spid  regurgitation  made.  Pulse  hard  as  a  telegraph  wire. 
Cheyne-Stokes  respiration.  Relief  was  afforded  by  the  nitrites. 
Patient  died  of  oedema  of  the  lungs.  At  the  post-mortem  examina- 
tion the  pericardial  sac  was  found  to  contain  eighteen  ounces  of  clear 
serum.  The  heart  weighed  twenty-seven  ounces  and  was  hyper- 
trophied,  especially  the  left  ventricle ;  the  right  was  thinned  and 
dilated.  Aortic  and  mitral  valves  sufficient.  Commencing  aneuris- 
mal  dilatation  of  the  aorta.  Pulmonary  orifice  dilated  and  insuffi- 
cient.     Liver  enlarged  and  of  a  dark  color.     Diffuse  nephritis. 

Case  XXIII.  Aortic  and  pulmonary  insufficiency,  due  to  ad- 
hesive pericarditis,  etc. — A  man  of  thirty-four,  Ireland,  black- 
smith. Admitted  to  hospital  September  18,  1885.  In  the  preceding 
January  he  had  a  cough  and  six  weeks  previously  haemoptysis,  losing 
about  1 3^  ounces  of  blood.  Had  suffered  from  acute  inflammatory 
rheumatism.  On  examination  the  heart's  apex  was  found  in  the 
fifth  space,  2^  inches  from  the  median  line.  Soft  systolic  murmur 
over  the  aortic  and  also  over  the  pulmonary  area,  with  accentuation 
of  the  second  pulmonary  sound.  Dulness  with  cavernous  breathing 
over  second  and  third  left  interspaces.  Below,  amphoric  breathing. 
At  right  apex  some  signs  of  softening. 

The  patient  died  of  cardiac  failure  October  3.  At  the  post-mor- 
tem examination  it  was  found  that  the  heart  w^eighed  only  12  ounces. 
The  heart  substance  was  soft  and  flabby ;  walls  thinned  and  cavities 
dilated.  Slight  fatty  change  in  mitral  leaflets.  Aortic  and  pul- 
monary valves  seat  of  numerous  small  perforations  ;  j^ericarditis.  It 
was  held  at  the  autopsy  that,  owing  to  the  relaxed  condition  of 
the  walls  from  the  adhesive  pericarditis,  the  valves  must  have  been  to 
some  extent  insufficient.  Cavities  in  apices  of  both  lung-s.  Paren- 
chymatous nephritis,  etc.  A  diagnosis  of  aortic  disease  had  been 
made.  This  was  not  a  satisfactory  case  from  several  points  of  view, 
but  it  is  none  the  less  on  record  as  one  of  aortic  and  pulmonarv  in- 
sufficiency, and  I  therefore  record  it.  It  seems,  too,  as  if. this 
diagnosis  accords  best  with  the  auscultatory  phenomena  and  the 
post-mortem  findings. 

Pinhole  openings  in  the  valves  are  sometimes  found  as  the  re- 
sult of  congenital  malformation.      They  never  cause  murmurs,  but 


Pulmonary   Valve   Affections  85 

good-sized  openings  and  clefts  may  cause  them.  The  pulmonary 
area  is,  of  all  valvular  areas,  the  most  likely  to  lead  to  error  for  the 
reason,  among  others,  that  it  is  so  close  to  the  aortic.  In  fact,  as 
already  stated,  aortic  murmurs  may  sometimes  be  heard  best  over 
the  pulmonary  area,  and  vice  versa.  Or  they  may  be  best  heard 
above  the  second  left  cartilage  or  over  the  sternum  opposite  to  it. 
But  there  are  murmurs  heard  over  the  pulmonary  area  that,  so  far 
as  we  know,  are  quite  independent  of  valvular  disease,  being  due  to 
anaemia,  change  of  position,  etc.,  etc.  Hence  the  danger  of  attaching 
too  much  importance  to  auscultatory  signs  at  this  point. 

Congenital  insufficiency  of  the  tricuspid  is  apt  to  be  associated 
with  pulmonary  stenosis  and  insufficiency.  Insufficiency  may  be 
found  at  any  age.  Barie  found  it  between  the  ages  of  three  and 
seventy-five  in  acquired  cases.  It  does  not  seem  to  have  any  prefer- 
ence in  the  matter  of  sex. 

According  to  Pitt,  whose  statistics  are  based  on  the  largest  num- 
ber of  tabulated  cases,  the  chief  cause  given  was  ulcerative  endo- 
carditis ;  while  next  in  importance  were  pulmonary  stenosis,  aortic 
aneurism  and  pulmonary  dilatation,  or  some  abnormality  in  the 
formation  of  the  valves.  In  this  connection  it  may  be  stated  that 
Barie  found  dilatation  of  the  pulmonary  artery  in  sixteen,  or  27 
per  cent.  Among  the  causes  given  by  Pitt  for  the  ulcerative  form 
v/ere  gonorrhoea,  puerperal  fever,  pyaemia  and  pneumonia ;  while 
associated  with  the  abnormalities  were  patent  ventricular  septa  and 
patent  ducts  of  Botalli.  Stenosis  causing  insufficiency  may  also  be 
due  to  adhesions  of  leaflets. 

The  congenital  form,  which  is  pretty  certain  to  be  associated 
with  stenosis  and  cardiac  anomalies,  will  be  readily  recognized  by 
a  general  cyanosis  of  intense  character,  clubbed  fingers  and  toes,  and 
an  abnormal  development  of  the  chest.  In  these  cases  the  murmur 
is  soft,  because  the  blood  stream  lacks  vigor  and  there  are  no  ulcera- 
tions. In  the  acquired  form  there  are  apt  to  be  (together  with 
cyanosis  and  dyspnoea)  signs  of  defective  nutrition,  as  shown  in 
my  cases ;  for  all  four  had  chronic  pulmonary  disease  with  cough, 
dyspnoea  and  hemoptysis,  and  two  of  them  had  night  sweats. 

The  most  important  physical  signs  of  pulmonary  insufficiency 
are,  according  to  my  returns:  i.  Displacements  of  the  apex.  2. 
Diastolic  thrills  in  the  second  or  third  left  space  (in  20  per  cent., 
Barie)  from  the  edge  of  the  sternum  to  a  distance  of  one  inch 
to  the  left  of  it,  and  conducted  down  the  left  edge  of  the  sternum 
(Boyd).^    3.  Double  murmurs  (in  about  25  per  cent).    4.   Diastolic 


Boyd,  Scott.  Med.  and  Surg.  Journal.  1889,  Vol.  IV,  p.  121. 


fcC  Pulmonary    Valve   Affections 

bruits  intensified  by  inspiration.  5.  implications  of  the  lungs.  6. 
Munnurs  intcnsifieil  in  the  sitting  position.  7.  When  a  long  breath  is 
taken  a  jerk\  vesicular  murmur.  8.  Hemoptysis.  ().  Dyspnoea. 
10.  I'sually.  but  not  always,  hypertrophy  of  the  right  ventricle.  11. 
Epigastric  pulsation.  The  pulse  has  no  distinctive  character. 
Often  there  will  be  no  bruit  at  all.  We  must,  however,  discrim- 
inate against  aortic  disease  (insufficiency)  by  the  absence  of  hyper- 
trophy of  the  left  ventricle  and  by  the  Corrigan  pulse.  The  mur- 
nnir  should  be  louder  than  the  aortic. 

According  to  Barie.  the  diagjwsis  was  made  in  but  thirteen  out 
of  fifty-eight  cases  (22  per  cent.).  According  to  Pitt,  the  diagnosis 
was  made  in  more  than  half  his  septic  cases.  The  ulcerative 
process  seems  to  be  necessary  to  cause  murmurs.  I-Iowever,  the 
diagnosis  would  certainly  be  made  more  frequently,  if  physicians 
would  be  systematic  in  their  examination  of  the  heart,  whenever 
there  is  a  suspicion  of  cardiac  disease,  making  notes  of  all  the  mur- 
murs at  the  four  valces.  as  I  have  urged  in  a  former  chapter. 

The  prog)iosis  is  unfavorable  in  congenital  disease.  Acquired 
cases  have  been  known  to  live  to  seventy-five.  My  four  acquired 
cases  reached  ages  between  thirty-four  and  fift}-six  ;  for  after  all, 
efifective  compensation  may  be  established  by  hypertrophy 
of  the  right  heart,  just  as  in  tricuspid  regurgitation,  with 
which  it  is  so  generally  associated.  And  because  general 
malnutrition,  and  infections  like  gonorrhoea,  measles  and  syph- 
ilis, and  phthisis,  are  potent  factors,  the  success  or  lack  of  it  in 
treating  these  maladies  must  largely  influence  the  expectation  of 
life.  So  that  in  prophylaxis  and  treatment,  infections  must  be  avoided 
and  combated,  and  special  care  given  to  pulmonarv  implications. 

When  there  is  sepsis  from  infection,  the  use  of  the  newer  antis- 
treptococcus  sera  offers  hopes  of  cure ;  they  are  certainly  worthy 
of  consideration,  if  used  in  conjunction  with  other  appropriate  symp- 
tomatic measures.  The  lung  affection,  of  course,  should  have  the 
first  attention. 

Pulmonary  stenosis  or  obstruction  is  one  of  the  most  frequent 
of  the  many  congenital  cardiac  anomalies  which  defy  classification, 
owing  to  their  varieties.  Uusually  this  valve  defect  is  associated 
with  abnormalities  of  the  large  vessels  as  w-ell ;  with  imperfections 
of  the  inter-auricular  or  inter-ventricular  septa,  or  of  valve  leaflets. 
The  two  most  common  anomalies  are  patency  of  the  foramen  ovale 
and  of  the  septum  between  the  ventricles. 


Pulmonary   Valve   Affections  87 

'  Usually  the  valve  defects  are  curious  rather  than  dangerous  to  life, 
for  though  the  valves  may  be  irregular  in  number  or  shape,  or  the 
leaflets  improperly  implanted,  they  often  do  their  work  satisfac- 
torily. But  when  the  valves  are  not  separated,  are  twisted  or  miss- 
ing, whether  from  imperfect  or  arrested  development  or  prenatal 
inflammation,  so  that  the  calibre  of  the  outlet  is  afifected,  the  expec- 
tation of  life  will  be  seriously  altered.  But  simple  thickening  of 
the  leaflets  may  be  due  to  intra-uterine  disease  or  to  senile  change. 
If,  however,  the  function  of  the  valve  is  not  interfered  with  the  ab- 
normalitv  may  be  of  trivial  importance ;  but  endocarditis  of  the  pul- 
monary valve  is  a  very  serious  matter,  as  it  easily  destroys  these  seg- 
iments,  which  are  extremely  delicate,  and  so  permanent  insufficiency 
may  be  produced. 

One  of  the  most  common  of  the  associated  extracardiac  anoma- 
lies is  the  persistence  after  birth  of  the  ductus  arteriosus,  which 
in  foetal  life  connects  the  pulmonary  artery  with  the  descending 
aorta. 

Still  we  must  recognize  that,  in  a  measure,  one  defect  compen- 
sates another.  If,  for  example,  there  should  happen  to  be  complete 
closure  of  the  pulmonary  artery,  the  patency  of  the  ductus  arte- 
riosus would  be  a  compensatory  defect,  permitting  the  aorta,  through 
the  duct,  to  supply  the  lungs  with  blood.  And  so,  if  the  tricuspid 
happened  to  be  closed  the  patent  foramen  ovale  would  allow  the 
blood  from  the  right  auricle  to  pass  to  the  left  auricle.  Among 
other  minor  anomalies  we  also  occasionally  find  strictures,  either  of 
the  pulmonar}^  artery  or  one  of  its  branches,  or  narrowing  of  the 
infundibulum,  which  lies  beneath  the  pulmonary  valves.  There  are 
on  record  a  number  of  cases  presenting  these  and  other  anomalies. 
In  fact,  the  pathological  department  of  any  hospital  caring  for  in- 
fants or  young  children  would  naturally  have  frequent  instances  of 
these  defects.  This  is  true  of  the  Babies'  Hospital  of  this  city,  with 
which  I  am  connected.  In  a  comparatively  small  number  of  cases 
stenosis  (obstruction)  is  acquired.  What  the  ratio  between  these 
congenital  and  acquired  stenoses  is,  I  do  not  know.  It  is  a  difficult 
matter  to  determine,  even  with  pretty  complete  clinical  and  post-mor- 
tem records  at  hand.  Many  of  the  older  reports  do  not  make  it  plain. 
In  fact,  it  was  not  attempted  until  the  time  of  Constantine  Paul  in 
1871.  Besides,  in  many  instances  an  acquired  lesion  like  endo- 
carditis is  engrafted  on  a  congenital  malformation. 

As  a  single  congenital  lesion,  pulmonary  stenosis  is  a  great  rar- 
ity.    Fortunately,  through  the  assistance  of  Dr.   Wallstein,   Path- 


88  Pulmonary   Valve  Affections 

ologist  of  the  Babies'  Hospital.  I  am  able  to  record  one  case,  which 
I  have  already  alluded  to.     It  is  the  following": 

Case  XXIF.  Stenosis  of  Piihiioiiary  In  an  Infant. — An  infant 
of  five  months  died  at  the  hospital  after  the  following^  symptoms 
had  been  noted:  A  diffuse  apex  beat,  and  a  systolic  murmur  at  the 
base,  heard  with  greatest  intensity  at  the  left  of  the  sternum  and 
transmitted  \\y>  the  neck  on  both  sides.  Diagnosis  not  made.  No 
c\anosis.  At  the  autopsy  the  puhuonary  orifice  was  found  one- 
third  smaller  than  normal.      Xo  other  cardiac  lesion. 

It  will  be  noted  from  this  case  that  obstruction  (stenosis)  of  the 
pulmonar}-  does  not  necessarily  produce  cyanosis.  Pitt  (Albutt's 
System.  \'ol.  VII.  p.  9)  has  collected  fourteen  cases  of  acquired 
stenosis.  I  have  collected  and  verified  fifteen,  yet  have  failed  to 
get  access  to  at  least  one-half  of  the  literature  on  this  subject.  The 
references  to  my  cases  I  give  here: 

Ebstein,  Dcutsches  Arch.  f.  klin.  Med.  Bd.,  VII..  s.  281. 

Peacock,  Lancet,  1868,  Vol.  I. 

Rindrteisch  and  Oberneier,  Deutsches  Arch.  f.  klin.  Med.,  Bd.  V.,  s.  539. 

Mayer  and  Oberneier,  Deutsches  Arch.  f.  klin.  Med.,  Bd.  XXIV.,  s.  435. 

Whitley,  Guy's  Hosp.  Repts.,  III.,  1857,  p.  255. 

Whitley,  Guy's  Hosp.  Repts.,  III.,  1857,  p.  255. 

Paget,  Med.  Chir-Trans.,  1844,  p.  182. 

Crudelli,  Riv.  Clin.  di.  Torino.,  VII.,  2  p.  37-68.     Schmidt's  Jahrb.  8,  1870. 

Berlin,  Heart  Diseases,  1821. 

Constantine  Paul,  Soc.  Med.  de  Hop.  de  Paris,  T.  VIII. 

Schwalbe,  Virchow's  Archiv.,  Bd.  119,  S.  2,  s.  45,  1890. 

Schvvalbe,  Virchow's  Archiv.,  Bd.  119,  S.  2,  s.  45,  189a 

Schwalbe,  Virchow's  Archiv.,  Bd.  119,  S.  2,  s.  45,  1890. 

Wagner,  Archiv.  f.  Heilk.,  1866,  s.  518. 

Colberg,  Deutsches  Archiv.  f.  klin.  Med.,  Bd.  5,  s.  565. 

I  am  inclined  to  think  that  the  following  case  was  also  one  of 
temporary  stenosis,  caused  by  extracardiac  pressure,  relieved  by 
evacuation  of  an  abscess.  Otherwise  I  have  none  in  my  post-mortem 
records. 

Case  XXV.  Probable  Stenosis  of  the  Pulnioncj-y  Artery. — A 
groom,  age  twenty-eight  years,  was  admitted  to  hospital  in  July, 
1883,  with  an  abdominal  tumor  continuous  with  the  liver  and  extend- 
ing into  the  epigastric  and  right  hyperchondriac  regions.  Palpable 
pulsation  over  the  pulmonary  area,  extending  up  to  and  under  the 
clavicle  and  attended  with  a  soft  systolic  bruit.  No  other  signs 
of  cardiac  disease.  In  the  following  month  two  incisions  were 
made  into  the  tumor  and  three  ounces  of  pus  removed  at  each  opera- 
tion. The  man  survived  the  operation,  but  died  of  progressive 
emaciation  and  sepsis.  At  the  autopsy  the  liver  was  found  to  be 
greatly  enlarged,  weighing  eighty-eight  ounces.     It  apparently  had 


Pulmonary   Valve   Affections  ^) 

•compressed  the  lung-s,  both  of  which  were  unusually  dry,  the  left 
■especially,  and  by  pressure  had  caused  the  same  kind  of  temporary 
stenosis  of  the  pulmonary  artery  that  is  sometimes  seen  when 
aneurisms  of  the  aorta  by  pressure  alter  the  calibre  of  the  vessel 
from  a  circular  to  a  crescentic  form. 

In  congenital  disease  the  cause  must  be  laid  to  lack  of  develop- 
ment. In  the  acquired  form,  infection,  according  to  my  tables,  plays 
a  most  important  role,  the  order  of  frequency  being  rheumatism, 
aneurism,  syphilis,  gonorrhoea.  Doubtless  further  researches  into 
the  etiology  of  this  subject  will  enlarge  the  number  of  causes,  affect- 
ing the  ratio  here  given.  Pitt,  in  his  fourteen  cases,  found  rheuma- 
tism a  causal  factor  in  eight,  or  57  per  cent.  Males  and  females  ap- 
pear to  be  about  equally  affected. 

In  symptomatology  there  is  a  wide  difference  between 
the  congenital  and  the  acquired  forms.  In  the  former 
there  is  usually  general  cyanosis,  though  not  always,  as  in 
the  instance  I  have  here  given.  There  is  ordinarily  a 
lack  of  physical  and  mental  developm.ent.  The  patient  complains 
of  headache  and  is  somnolent,  or  has  hebetude ;  is  undersized,  and 
has  a  bulging  chest  and  a  protruding  abdomen.  There  is  defective 
development  of  the  genitals,  with  clubbed  fingers  and  toes.  The 
eyes  may  be  prominent.  The  physical  signs  are  not  very  distinctive. 
The  right  ventricle  is  enlarged  in  complicated  cases ;  both  are  en- 
larged when  the  left  ventricle  is  called  on  for  extra  work.  The 
murmur  is  systolic  and  usually,  if  there  are  vegetations,  loud,  it 
may  be  heard  all  over  the  praecordial  area,  but  its  intensity  is  apt 
to  be  greatest  over  the  pulmonary  area,  i.  e.,  the  second  left  inter- 
costal space,  close  to  the  sternum.  In  addition  it  is  continued  up 
towards  and  sometimes  under  the  clavicle.  Exceptionally  it  may 
be  best  heard  lower  down.  In  one  case*  (Hun's)  it  was  best  heard 
at  the  fifth  left  sterno-costal  junction. 

In  acquired  obstruction  we  should  look  for  an  antecedent  infec- 
tion, and  especially  for  venereal  disease  or  rheumatism.  As 
distinguished  from  the  congenital  form,  there  is  less  often  cyano- 
sis in  the  acquired ;  and  there  are  none  of  the  characteristics 
of  arrested  mental  and  physical  development.  But  if  there  is  cyano- 
sis it  is  increased  by  coughing,  and  dyspncea  is  present.  The  mur- 
mur is  more  definitely  located  than  in  the  congenital  form,  because 
the  force  of  the  stream,  is  undiminished  by  defects  in  the  walls  of  the 
heart.  It  should  be  loud  and  rasping  in  the  endocarditis  forms. 
If  the  patient  hold  his  breath  it  should  be  somewhat  fainter.     The 


*  Albany  Med.  Annals,  pp.  57-66,  1897. 


90  Pulmonary   Valve   Affections 

apex  beat  is  apt  to  be  forcible  and  tlittuse.  and  there  may  be  a  thrill. 
Tlie  second  pulmonary  sound  should  be  faint,  but  there  may  be 
insufficiency  and  a  double  nuu-iuur.  The  imirniur  is  apt  to  be 
propagated  from  the  base  of  the  heart  up  toward  the  left  shoul- 
der, as  far  as  the  clavicle.  The  jioint  of  g^reatest  intensity  is  usu- 
ally in  the  secontl  left  interspace.  l'suall\-  there  is  an  attend- 
ant pulmonary  or  bronchial  disease,  of  a  purulent  character. 

When,  as  in  the  case  1  have  given,  the  pulmonar}-  stenosis  is 
single,  hyi)ertn)])hy  sliould  be  conhned  to  the  right  heart.  If  for 
an\-  reason  the  left  heart  has  been  called  on  for  extra  work  it  will 
naturally  hypertrophy.  There  is  nothing  characteristic  about  the 
pulse.  Some  oedema,  even  anasarca  and  albuminuria,  may  be  ex- 
pected toward  the  end. 

The  diagnosis  is  never  easy.  Even  in  the  congenital  forms  pul- 
monary stenosis  is,  as  a  rule,  as  I  have  said,  only  one  of  many 
anomalies ;  two  at  least  of  them,  viz. :  the  patency  of  the  foramen 
ovale  and  of  the  interventricular  septum,  capable  of  producing  in 
the  one  a  diastolic,  and  the  other  a  systolic  murmur.  In  infants 
it  is  hard  to  distinguish  between  the  two ;  but  as  all  heart  anomalies 
afe  apt  to  center  about  ])ulmonary  stenosis,  a  bold  guess  will  some- 
times be  rewarded  with  success.  In  acquired  cases,  even  when  they 
have  been  most  carefully  studied  as  to  every  auscultatory  detail,, 
the  diagnosis  has  seldom  been  made.  Paul  and  Mayer,  however,. 
have  each  recorded  a  successful  antemortem  diagnosis. 

The  prognosis  is  never  good.  Exceptionally,  congenital  caseS' 
have  lived  to  forty ;  usually  they  die  before  the  fourth  year  of  life,, 
and  of  tuberculosis. 

In  the  acquired  form  the  prognosis  is  more  favorable.  One 
of  Schwalbe's  patients  lived  to  be  eighty-four,  another  to  be 
sixty-eight,  while  Rindfleisch  and  Oberneier's  died  at  sixty-five. 
Usually,  however,  they  do  not  survive  the  third  decade. 

It  is  well  to  remember  that  at  the  birth  of  infants  having 
this  malformation,  after  removing  the  mucus  from  the  mouth  and 
nostrils,  the  circulation  should  be  stimulated  by  slapping  the  surface. 
Artificial  respiration  by  Sylvester's  method,  the  author's  or  others, 
should  also  be  resorted  to  ;  or  the  lungs  may  be  inflated  by  the  cathe- 
ter, introduced  through  the  larynx.  After  the  circulation  has  been  es- 
tablished in  this  way,  the  infant  should  be  kept  in  a  warm,  dry  room. 
In  general,  patients  with  this  congenital  malformation  should  live 
an  uneventful  life,  in  a  warm,  equable  climate.  They  should  have 
systematic   exercise   and   their   diet   should   be   carefully   regulated. 


Pulmonary   Valve   Affections  91 

Their  methods  of  life  should  be  such  tliat  they  have  no  physical 
or  mental  strain.     Matrimony  should  be   sternly  prohibited. 

In  the  acquired  form  infections  and  rheumatic  tendencies  should 
be  combated ;  and  the  cardiac  symptoms  should  be  met,  as  they 
arise,  with  appropriate  treatment. 


Chapter  VIII. 

TRICUSPID  DISEASES.^ 

Serious  affections  of  the  tricuspid  are  comparatively  rare  and, 
with  the  exception  of  pulmonary  valve  diseases,  are  the  most  un- 
common. They  are  still  more  rarely  single.  Gibson,  however, 
maintains  that  tricuspid  insufficiency  is  the  most  common  of  valvu- 
lar diseases,  while  Sperling  makes  the  incidence  26  in  100  of  com- 
bined lesions,  and  three  out  of  200  of  single  lesions.  In  44  cases 
of  valve  disease  as  shown  by  post-mortems  I  found  the  incidence  12, 
or  27  per  cent.,  while  I  have  observed  no  single  cases.  Tricuspid 
insufficiency  is  usually  relative,  and  due  to  many  causes,  cardiac  and 
extra-cardiac. 

Organic  lesions  of  the  tricuspid  valve,  due  to  endocarditis  or 
atheroma,  are  usually  consecutive  to  mitral  or  aortic  diseases ;  or  to 
general  arterio-sclerosis.  Insufficiency  and  stenosis  are  the  two  forms 
recognized.  Tricuspid  insufficiency  is  the  most  common,  and  the 
number  of  recorded  instances  must  easily  run  up  into  the  thousands, 
for  in  Guy's  Hospital  alone  405  have  been  recorded.  These  figures 
are  in  striking  contrast  to  the  published  cases  of  tricuspid  stenosis, 
which  in  1897,  according  to  Herrick,-  had  only  reached  154;  so  that 
although  tricuspid  insufficiency  is  comparatively  rare,  it  is  as  com- 
mon, as  compared  with  stenosis,  as  the  latter  is  rare. 

Tricuspid  insufficiency  may  be  congenital  or  acquired;  organic 
or  relative.  Ordinarily  we  see  the  relative  (acquired)  form,  which 
is  due  to  stretching  of  the  valves,  from  dilatation  of  the  right  ven- 
tricle consecutive  to  chronic  affections  of  the  lungs,  or  enlargement 
of  the  heart,  whether  from  fatty  changes  or  some  other  form  of  hy- 
pertrophy ;  perhaps  from  adherent  pericardium.  There  are  also 
other  causes.  In  one  of  my  cases  the  tricuspid  was  apparently  di- 
lated from  pressure  on  the  right  auricle  b}-  an  aneurism  of  the  as- 
cending arch,  and  the  insufficiency  was  discovered  during  life.  Tri- 
cuspid insufficiency  is  furthermore  a  legitimate  sequel  to  organic 
diseases  of  the  left  heart,  and  it  may  occur  in  the  last  stages  of  all 
these  diseases.  The  preponderance  of  the  relative  variety  over  the 
organic  is  well  shown  in  the  records  of  the  405  Guy's  Hospital  cases 


'  Originally  published  in  the  Med.  News,  Sept.  6,  1902. 
'  Boston  Med.  and  Surg.  Jour.,  March,  1897,  No.  i. 


Tricuspid  Diseases  93 

already  referred  to,  where  394,  or  about  97  per  cent.,  were  classed 
as  relative.      My  tables  make  it  about  90  per  cent. 

The  question  of  insufficiency,  however,  has  been  disputed,  even 
at  the  post-mortem  table,  some  holding  that  perfect  competency  is 
uncommon,  because  in  applying  the  water  test  there  will  often  be  a 
little  oozing  through  the  valve.  As  a  matter  of  fact,  such  fine  distinc- 
tions have  little  practical  value,  because  a  slight  oozing  is  not  recog- 
nizable during  life  by  any  ordinary  symptoms,  and  at  any  rate  may  be 
a  temporary  afifair  and  of  slight  importance.  For  this  minor  degree 
of  insufficiency  may  be  due  to  faulty  technic  on  the  part  of  the  op- 
erator, who  fails  to  hold  the  organ  squarely  in  his  hand  while  apply- 
ing the  test.  Practically,  unless  a  good-sized  stream  of  water  can 
be  passed  through  the  valve  when  the  organ  is  held  properly  in 
position,  it  should  be  regarded  as  competent.  Besides,  the  ring  of 
the  valve  is  well  supplied  with  smooth  muscle  fibres,  and  the  some- 
what relaxed  condition  sometimes  found  at  autopsies  may  be  due 
to  general  muscular  relaxation  which  has  occurred  in  the  last  hours 
of  life,  or  even  after  death.  Organic  insufficiency  is  almost  always 
due  to  endocarditis,  and  is  a  late  manifestation  of  the  general  impli- 
cation of  the  valves,  which  by  preference  first  attacks  the  mitral  and 
then  the  aortic. 

Relative  insufUciency  is  simply  the  result  of  physiological  laws. 
When  from  any  cause  there  is  obstruction,  or  stasis,  or  slowing  in 
the  pulmonary  veins,  due  either  to  chronic  pulmonary  disease  or  to 
disease  of  the  left  heart  or  pericardium,  causing  engorgement  of  the 
lungs  with  venous  blood,  the  current  of  blood  passing  through  the 
pulmonary  artery  finds  an  obstacle  ahead  of  it.  Consequently  the 
right  heart  dilates,  and  then  hypertrophies,  in  order  to  force  the 
blood  into  the  lungs.  This  dilatation  has  the  effect  of  stretching 
the  soft  muscular  substance  of  the  tricuspid  ring,  causing  insuffi- 
ciency; and  yet  this  relaxation  may,  after  a  time,  be  overcome  by 
the  general  hypertrophy.  Later,  however,  Avhen  the  right  ventricle 
begins  to  tire  and  contract  irregularly  from  weariness  or  degenera- 
tion of  its  fibres,  the  muscular  tissue  of  the  ring  will  also  participate 
in  the  degeneration  and  again  become  incompetent.  This  is  one 
of  the  common  incidents  of  heart  failure,  in  the  last  stages  of  valvu- 
lar disease. 

In  other  enlargements  of  the  heart,  as  in  fat  deposition  and  in 
chronic  fibrous  nephritis,  a  certain  amount  of  enlargement  of  the 
elements  of  the  valve  may  take  place  and  even  keep  pace  with  the 
enlargement  of  the  heart  walls ;  for  it  is  known  that  in  valvular  dis- 


94  Tricuspid  Diseases 

ea^es  even  tlie  leartets  soinclimes  enlarge,  in  order  to  close  the  ori- 
fice which  ihey  are  intended  ti>  protect.  If.  however,  there  has  been 
any  deposit  in  the  substance  vi  the  valve  of  a  librous  nature,  con- 
traction, rather  than  expansion,  must  take  place. 

As  soon  as  tricusi)id  insufficiency  has  become  established  a  col- 
umn of  blood  is  forceil  throui;h  the  tricuspid  vah'e  into  the  right 
auricle  which  also  dilates  and  later  nia\  hypertrophy  ;  but  the  s_\stolic 
action  of  the  right  ventricle,  acting  on  the  blood  contained  in  the 
right  auricle,  communicates  its  impact  to  the  systemic  veins,  dilating 
them,  provided  the  dilatation  reaches  such  a  tlegree  that  the  venous 
valves  are  no  longer  competent.  And  so  the  blood  in  the  veins 
pulsates.  This  jjhenomenon  of  z'ciioiis  f>u!satio)i  is  always  best  seen 
in  the  veins  of  the  right  side,  because  thc\  are  in  the  direct  line 
of  the  blood  current  as  propelled  through  the  insufficient  tricuspid. 
As  venous  pulsation  is  specially  well  seen  in  the  jugulars,  it  is  called 
jugular  pulsation.  For  the  superior  vena  cava  and  the  innom- 
inate veins  have  no  valves,  so  that  no  bar  to  the  backward  wave  is 
felt  until  they  have  been  passed  ;  while  at  the  right  sternoclavicular 
articulation  there  is  a  valve  in  the  jugular  vein,  which  resists  the 
wave,  and  in  fact  produces  a  dilatation  below  the  valve,  which 
is  called  the  jugular  bulb,  where  the  vein  is  expanded  into  a  rounded 
body  that  may  be  seen  or  felt.  In  many  instances  of  tricuspid 
insufficiency  the  backward  wave  does  not  progress  beyond  this 
point ;  the  veins  are  simpl}-  filled.  But  if  the  valve  gives  way, 
the  wave  is  propagated  onward  into  the  external  jugulars  and  sub- 
clavians,  and  may  mount  into  the  face. 

Distinct  pulsation  in  these  cervical  veins  is,  therefore,  an  import- 
ant sign  ;  and  yet  it  is  not  pathognomonic.  Further,  one  must  always 
distinguish  between  a  true  venous  pulsation  and  a  mere  undula- 
tion of  the  current  in  the  veins  which  occurs  apart  from  tricuspid 
disease — the  false  venous  pulse. 

True  jugular  pulsation  is  best  determined  by  pressing  down  the 
column  of  blood  in  the  cervical  veins,  when  the  impulse  will  be  found 
before  it.  not  behind  it.  Compression  of  the  carotids  cannot  be 
accomplished  without  using  considerable  force,  so  that  we  are  not 
likely  to  confound  one  with  the  other.  To  bring  the  bulb  of  the 
jugular  vein  into  view,  the  patient  should  be  made  to  cough,  when  it 
becomes  distinct. 

A  sign  that  has  been  given  by  Pasteur"  is  distention  of  the  veins 
•f  the  neck  with  or  without  pulsation,  when  the  liver  is  compressed 


Lancet,   1885,  p.  524. 


Tricuspid  Diseases  95 

.by  the  two  hands,  'i'liis  actio))  slows  the  blood  i))  the  i)iferior  vena 
•cava  and  causes  increased  tension  in  the  superior  vena  cava,  and  so 
in  the  cervical  veins.  In  my  cases,  however,  the  venous  pulse  was 
not  noted  as  a  prominent  symptom. 

Stasis  in  the  pulmonary  veins  of  the  lungs  prrxluces  c}-anosis  and 
•dyspnoea ;  in  the  systemic  veins  oedema  and  albuminuria. 

The  degree  of  stretching  possible  in  a  case  of  relative  insuffi- 
ciency was  well  shown  in  one  of  my  cases,  where  the  tricuspid  ad- 
mitted seven  fingers,  while  ordinarily  it  admits  only  two.  In  aver- 
age cases  of  insufficiency  it  will  admit  three  to  four  fingers. 

In  the  comparatively  rare  form  of  insufficiency,  the  organic,  the 
valves  and  their  rings  and  supporting  structures  become  infiltrated, 
thickened,  distorted,  and  perhaps  contracted ;  for  stenosis  presup- 
poses insufficiency.  Yet  if  the  stenosis  is  only  in  the  ring,  narrow- 
ing may  occur  without  insufficiency,  as  happened  in  one  of  my  cases 
of  aortic  stenosis.  Practically  then,  in  organic  tricuspid  insuffi- 
ciency, there  may  or  may  not  be  dilatation  of  the  outlet.  Atheroma 
rarely  attacks  the  tricuspid  valve. 

One  of  the  first  symptoms  is  cyanosis.  This  is  at  first  slight, 
but  may  become  extreme.  Associated  with  it  is  more  or  less  dysp- 
noea, depending  chiefly  on  the  grade  of  venous  stagnation  in  the 
lungs.  Oedema  of  the  hings  is  also  more  or  less  common,  and  for 
.a  like  reason  there  is  oedema  of  the  lower  extremities,  first  seen  in 
the  feet  and  then  slowly  rising  towards  the  trunk.  When  the  liver 
and  kidneys  become  indurated  we  may  expect  ascites  and  albumin- 
uria. One  of  the  jiiost  prominent  and  early  s}mptoms  is  the  venous 
pulse  which  has  been  described. 

Another  sign  is  epigastric  pulsation,  btit  it  is  appreciable  only 
when  the  cardiac  s}stole  is  forcible.  The  radial  pulse  is  usually 
small,  soft  and  ij'regular,  and  is  apt  to  be  frequent.  A  thrill  is  of 
rare  occurrence.  When  it  is  felt  it  is  probably  due  to  an  associated 
mitral  or  aortic  disease. 

The  most  characteristic  sign  of  tricuspid  insufficiency  is  the  sys- 
tolic murmur  over  the  tricuspid  area.  It  should  be  heard  with 
greatest  intensity  over  the  lower  half  of  the  sternum,  at  the  root  of 
or  over  the  ensiform  cartilage  (the  nearest  point  to  the  tricuspid), 
to  the  right  of  the  median  line  :  occasionally  as  far  as  the  right  axilla 
•or  to  the  left  of  the  sternum  at  the  left  fifth  costosternal  junction 
(Cabot)  or  just  above  it.  It  should  not.  however,  be  propagated 
any  considerable  distance  to  the  left.  The  murmur  is  usually  soft 
.and  faint.      Exceptionally  it  is  rough  and  harsh. 


96  Tricuspid  Diseases 

The  second  pulmonary  sound,  so  far  as  has  been  noted,  is  weak^ 
because  a  comparatively  small  amount  of  blood  is  propelled  into  the 
pulmonary  artery.  Doubtless  in  a  very  large  number  of  these  cases 
there  has  at  some  time  been  an  accentuation  of  the  second  sound, 
owing  to  the  accompanying  mitral  disease ;  but  on  the  failure  of  the 
tricuspid  this  symptom  disappears,  and  the  weakness  of  the  second 
pulmonary  sound  is  theretore,  at  this  period,  an  important  sign  as  in- 
dicating an  advance  in  the  general  valvular  disease.  This  symp- 
tom, however,  is  one  to  which  but  little  attention  has  been  paid. 

Undoubtedly  tricuspid  insufficiency  produces  at  first  dilatation. 
and  then  hypertrophy  of  the  right  auricle,  and  this  is  noticeable  in 
some  cases,  chietly  at  the  level  of  the  right  auricle.  The  heart  in 
its  totality  is  not  enlarged,  however,  when  the  insufficiency  has  been 
of  short  duration. 

In  the  heart  failure  which  is  so  frequent  an  event  in  tricuspid 
insufficiency  one  often  sees  the  facial  discoloration,  the  wild  expres- 
sion, the  projecting  eyes.  The  patient  leans  forward,  as  this  position 
is  the  most  favorable  for  respiration,  and  gasps  for  breath,  owing  to 
the  stagnation  of  blood  in  the  lungs.  The  veins  stand  out  in  the 
neck.  Often  he  can  hardly  speak,  and  only  in  monosyllables.  The 
radial  pulse  is  weak  and  intermittent.  The  heart  s  action  is 
tumultuous. 

Yet  tricuspid  insufficiency  is  seldom  recognized  during  life,  even 
under  favorable  circumstances.  In  29  cases  proved  by  autopsies  at 
the  Massachusetts  General  Hospital  but  five,  or  17  per  cent.,  were 
recognized  during  life.  In  ten  cases  from  my  post-mortem  records 
the  diagnosis  was  made  in  three,  or  30  per  cent.  But  by  some  the  di- 
agnosis is  regarded  as  a  refinement  of  comparatively  little  importance, 
in  the  presence  of  other  conditions  more  apparent,  and  even  more 
immediately  serious  to  the  individual. 

The  most  distinctive  sign,  as  I  have  said,  is  a  systolic  murmur 
over  the  lower  half  of  the  sternum  and  ensiform  cartilage,  the  most 
common  center  of  the  greatest  intensity  being  (according  to  my  re- 
turns) the  fourth  left  intercostal  space  close  to  the  sternal  margin. 
At  times  the  greatest  intensity  is  as  low  as  the  fifth  left  intercostal 
space,  close  to  the  sternum,  and  the  corresponding  area  on  the  right 
side ;  sometimes  as  much  as  an  inch  to  the  right  of  these  points, 
so  that  on  the  whole  this  area  is  somewhat  broader  on  the  right  side 
than  on  the  left.  Occasionally  the  murmur  may  be  carried  to  the 
right  axilla,  but  it  is  seldom  carried  much  to  the  left 
of  the  sternum.      As  the  tricuspid,  however,  is  a  large  and  rather 


Tricuspid  Diseases  97 

indeterminate  areas  as  compared  with  the  mitral,  which  overlaps  it, 
it  is  essential  for  purposes  of  diagnosis  that  the  two  sounds  or  mur- 
murs in  these  two  areas  should  be  appreciably  dififerent  in  character 
as  to  pitch,  quality,  duration  or  intensity ;  and  the  propagation  of 
the  murmurs  should  be  in  different  directions. 

Epigastric  pulsation  is  the  next  important  sign.  It  does  not: 
occur  in  simple  mitral  or  aortic  disease ;  but  we  should  remember 
that  tricuspid  disease  may  be  associated  with  organic  mitral  dis- 
ease in  from  20  to  25  per  cent. ;  and  with  organic  aortic  disease  in. 
from  15  to  17  per  cent.     It  may,  however,  be  absent. 

Faintness  of  the  second  pulmonary  sound  is  also  important,  es- 
pecially if  previously  there  has  been  accentuation  of  it. 

The  jugular  pulse,  once  thought  to  be  pathognomonic,  is  not  sO' 
regarded  now.  It  is  seen  in  other  conditions.  It  occurred  in  one 
of  my  cases  of  aortic  insufficiency,  without  tricuspid  disease.  Sim- 
ple fulness  of  the  jugulars  is,  however,  a  noteworthy  sign.  Increase 
in  the  transverse  dulness  of  the  heart  is  not  a  reliable  sign.  It  may 
occur  or  may  not.     It  may  not  exist  in  wasting  pulmonary  diseases. 

The  tricuspid  murmur  may  be  also  mistaken  for  the  murmur  of 
aortic  stenosis ;  or  the  latter  may  mask  the  former,  when  it  is  propa- 
gated backwards,  as  it  sometimes  is,  towards  the  apex.  However^ 
the  diagnosis  of  aortic  stenosis  should  be  established  by  the  propa- 
gation of  the  murmur  up  the  great  vessels.  Simple  thickening  of  the 
tricuspid  without  roughness,  like  simple  oozing,  gives  no  sign. 

In  general  the  prognosis  is  bad.  There  are  cases,  how^ever,  in 
which  heart  stimulants  will  sustain  the  flagging  heart  and  carry  the 
patient  into  a  region  of  comparative  safety.  In  fact,  successive 
attacks  may  be  mastered  in  this  way,  but  the  danger  is  always  near 
at  hand.  Still  the  prognosis  is  not  so  bad  in  the  relative  variety 
as  in  the  organic,  for  the  latter  presupposes  implication  of  other 
valves.  When  there  is  albuminuria  and  scanty  urine  the  prognosis 
is  worse. 

Case  XXVI.  Mitral  Stenosis:  Pulmonary,  Aortic  and  Tri- 
cuspid Insufficiency. — A.,  twenty-six  years  old,  single,  was  admit- 
ted to  hospital  September  18,  18S0.  Twelve  years  before  admission 
the  patient  had  a  severe  attack  of  rheumatism,  and  for  about  a  year 
had  suffered  from  more  or  less  of  palpitation  and  dyspnoea.  On  phys- 
ical examination  marked  pulsation  was  noted  in  the  epigastrium. 
Murmur  with  first  sound  at  the  apex,  not  heard  behind  or  in  the  ax- 
illa. Want  of  synchronism  between  the  two  radials.  H^•pertrophv  of 
heart.      Cyanosis,  nausea  and  scanty  urine.      The  dyspnoea  contin- 


98  Tricuspid  Diseases 

lied,  and  with  it  marked  pulsation  in  the  vessels  of  the  neck.  About 
live  weeks  after  admission  a  "purring:  thrill"  was  noted  in  the  fifth 
intercostal  space,  one  and  a  half  inches  below  the  nipple,  with  some 
recession  of  the  jsoft  parts,  more  distinct  during  inspiration.  Patient 
developed  orthopntva  and  died  in  a  uraMuic  convulsion. 

The  autopsy  showed  general  anasarca.  Heart  weighed  16  oz. 
Mitral  calcareous,  only  admitting  index  finger.  .-Vortic  slightly  in- 
sufficient. Tulmonary  insufficient.  Tricuspid  admits  tips  of  four 
fingers.  Right  ventricle  hypertrophietl.  Walls  of  left  ventricle 
thinned.  Fibrous  i^hthisis.  ( )edcma  of  the  lungs.  Nutmeg  liver. 
In  this  case  the  "purring  thrill"  of  mitral  stenosis  had  been  noted, 
as  this  was  the  predominating  lesion. 

Tricuspid  obstniction  or  stenosis,  for  they  both  appear  to  be 
synonymous,  is  one  of  the  most  uncommon  forms  of  valvular  dis- 
ease. In  1881  h'enwick*  had  been  able  to  collect  only  40  cases;  Pitt, 
of  London,  in  Albutt's  Syslcni  (Vol.  \TI,  p.  25),  only  87  cases 
during  a  period  of  26  \ears,  and  Merrick,  of  Chicago,'"'  154  cases  up 
to  1897.  Since  that  date,  however,  some  additional  cases  have  been 
published,  bringing  the  total,  according  to  my  reckoning,  up  to  162. 
These  figures  include  two  by  Whyte;"  one  by  Devic  and  Teyssier  ;^ 
tliree  from  the  records  of  the  Path.  Soc.  of  Phil.,  1898,  Vol.  XVIII, 
pp.  132,  181  and  196,  by  Packard,  Steele  and  McCarthy;  one  by 
Chadbourne,-  and  one  by  Sir  George  Dufifey."  Total  addition,  8 ; 
grand  total,  162. 

Tricuspid  obstruction  must  not.  however,  be  considered  as  an 
independent  disease.  It  is  almost  of  necessity  associated  with  tri- 
cuspid insufficiency,  just  as  any  valvular  stenosis  implies  insuffi- 
ciency. In  fact,  so  far  as  I  know,  there  has  never  been  a  case  of 
stenosis  without  insufficiency,  unless  it  is  one  reported  by  Duroziez, 
the  details  of  which  I  have  not  been  able  to  obtain.  And  in  only 
two  cases  (the  one  above  alluded  to  and  that  of  Devic  and  Teyssier) 
was  there  no  accompanying  mitral  stenosis.  Practically,  therefore, 
we  may  say  that  mitral  stenosis  is  a  constant  attendant  ou  tricuspid 
stenosis,  and  as  the  mitral  disease  is  the  older,  the  tricuspid  may 
be  regarded  as  a  comjilication  of  the  former.  It  is  a  very  serious 
one. 

The  former  idea  that  tricusjiid  stenosis  was  a  congenital  condi- 


*  Path.  Soc.  of  London.  1881,  p.  46. 

'Boston  Med.  and  Sure;.  Jour..  March,  1897,  Vol.  I. 

'Scott.    Med.  Jour.,  1890.  p.  18. 

^  Pror.  Med.  Lyons.  1900,  XV.,  p.  61,^. 

*  Ant.  Jour,  of  the  Med.  Sciences,  1900,  p.  306. 
'Dublin  Jour.,  1901,  p.  241. 


Tricuspid  Diseases  99 

lion  has  Ijccn  largely  abandoned,  certain]}-  in  post-fcetal  cases,  be- 
cause the  evidences  at  post-nif^rteni  of  its  being-  last  in  a  chain  of 
circumstances  are  pretty  positive,  -while  the  date  of  the  first  of  the 
events  (which,  so  far  as  the  valves  are  concerned,  is  mitral  dis- 
ease) can  be  proved  with  considerable  accuracy.  The  exceptions 
to  this  rule  are  so  rare  that  ])ractically  they  can  be  excluded. 

There  is,  of  course,  such  a  thing  as  congenital  stenosis,  which 
occurs  usually,  if  not  always,  in  association  with  other  congenital 
malformations  of  the  heart.  In  these  cases,  however,  life  is  rarely 
much  prolonged  after  birth,  so  that,  as  in  aortic  stenosis,  these  ex- 
ceptional forms  are  almost  never  seen. 

A  feature  of  great  diagnostic  importance  in  tricuspid  stenosis  is 
that  the  great  majority  of  the  sufferers  are  females.  In  Leudet's  loi 
cases  published  in  his  These  de  Paris,  1888^^  (as  quoted  by  Whit- 
taker),  80  were  women,  so  that  the  proportion  of  women  to  men 
v/as  about  four  to  one.  In  Fenwick's  46  cases,  of  which  41  were 
women,  the  ratio  of  women  to  men  was  about  nine  to  one.  In  12 
cases  that  I  have  collected  10  were  women,  or  five  to  i.  The  pre- 
ponderance in  favor  of  women,  therefore,  is  well  showai,  though 
the  reason  is  not  clear ;  but  whatever  arguments  tend  to  show  that 
mitral  disease  is  by  preference  a  feminine  lesion  should  apply  here. 

Fenwick  found  that  the  average  age  at  death  was  between  thirty- 
one  and  thirty-six.  In  my  collected  cases  the  average  fell  in  the 
thirties.     Very  few  survive  the  forties,  and  a  less  number  the  fifties. 

It  is  generally  accepted  that  rheumatism  is  the  most  frequent 
causative  factor.  Fenwick  found  it  in  50  per  cent. :  my  figures,  in 
10  cases,  accord  with  this  ratio.  In  half  of  them  we  have  to  look 
for  the  cause  in  influences  that  govern  mitral  diseases. 

The  heart  is  always  moderately  enlarged,  but  there  does  not  ap- 
])ear  to  be  much  enlargement  of  the  right  ventricle ;  indeed,  it  has 
sometimes  been  described  as  small.  The  right  auricle  is  usually 
dilated  and  hypertrophied,  its  walls  showing  manifest  thickening.  In 
tricuspid  stenosis,  coming  as  it  does  as  the  last  link  in  the  chain  of 
valve  events,  the  marked  organic  changes  seen  in  mitral  stenosis, 
are  not  apt  to  be  met  with.  \\>  usually  find  merely  an  agglutination 
of  the  segments,  causing  a  funnel-shaped  opening.  Ordinarily  it 
should  admit  two  or  three  fingers,  but  in  stenosis  it  may  admit  only 
one,  or  the  tip  of  a  finger.  The  substance  of  the  heart  must  bv  this 
time  have  degenerated  also,  and  we  find  induration  of  the  lungs, 
snleen  and  kidnevs,  with  the  nutmeg  liver. 


Of  the  12  cases  of  pure  tricuspid  stenosis  11  were  reported  by  Leudet. 


loo  Tricuspid  Diseases 

There  are  syniptO))is  in  abundance,  but  they  are  rarely  sufficiently 
distinctive  to  warrant  a  diagnosis. 

This  disease,  like  all  other  valvular  diseases,  advances  insidiously. 

The  patient  will  complain  of  palpitation.  In  one-half  of  the  cases 
there  is  cyanosis  (Pitt),  and  it  is  apt  to  be  extreme,  while  either  a 
fulness  or  pulsation  in  the  jugular  veins  may  be  observable.  With 
it  there  will  necessarily  be  dyspnoea,  and  perhaps  orthopnoea,  each  of 
tliem  severe.  In  75  per  cent,  of  the  cases,  according  to  Colbeck, 
there  is  albuminuria  or  dropsy.  On  palpitation  there  may  be  a  pre- 
systolic thrill,  anil  yet  the  tlirill  can  be  due  to  a  mitral  stenosis.  In  the 
epigastrium  there  will  be  pulsation,  at  times,  from  an  enlarged  liver 
'50  per  cent.,  says  Colbeck),  and  the  force  of  tlic  heart's  impulse 
will  be  marked.  The  presystolic  or  diastolic  murmur  in  the  tricus- 
pid area  (which,  according  to  English  ideas,  means  "over  the  fourth 
and  fifth  spaces  to  the  left  of  the  sternum")  should  be  heard  and 
was  heard  in  five  out  of  seven  of  Colbeck's  cases,  though  at  irregular 
intervals.  Some  locate  the  murmur  over  the  fifth  or  sixth  right 
cartilage  or  over  the  ensiform ;  others,  again,  over  the  lower  half 
of  the  sternum  and  as  much  as  an  inch  to  the  left  of  it ;  still  others,, 
at  the  root  of  the  ensiform  cartilage  or  to  the  right  of  it.  That  there 
is  some  kind  of  a  bruit  was  noted  in  the  tricuspid  area  in  20  only  of 
Fenwick's  32  cases.  It  should  dififer  in  pitch,  quality  and  duration 
and  perhaps  intensity,  from  the  associated  mitral  murmur,  and  this 
was  noted  in  Shattuck's  case  where  the  diagnosis  was  made  intrO' 
vitam}'^  In  about  one-quarter  of  the  cases  no  bruit  has  been  de- 
tected. In  about  one-quarter  of  the  cases,  also,  there  has  been  aortic 
stenosis.      Mental  confusion  or  hebetude  have  been  noticed. 

Thus  far  the  diagnosis  appears  to  have  been  made  only  in  six 
instances  (those  of  Colbeck  and  vShattuck)  out  of  the  162  which  I 
have  alluded  to.  Of  the  greater  number  it  may  be  said,  in  the  first 
place,  that  many  were  not  examined  thoroughly,  because  there  was 
no  opportunity  to  do  so;  and  second,  in  the  face  of  the  manifest 
mitral,  and  perhaps  aortic,  lesions,  no  special  interest  was  taken  in. 
those  of  the  tricuspid.  (3wing,  also,  to  the  inconstant  character  of 
the  murmur  and  usually  its  entire  absence,  it  is  not  so  strange  that 
the  diagnosis  has  been  seldom  made.  Indeed,  for  all  time  this  lesion 
will  be  apt  to  escape  notice,  if  we  are  to  depend  on  specific  ausculta- 
tory symptoms. 

More  constant  than  these  are:  (i)  A  coexisting  mitral  stenosis  r 
(2)  an  enlarged  and  dilated  right  auricle;  (3)  palpitation,  cyanosis,. 


Boston  Med.  and  Surg.  Jour..  Vol.  124.  i8gi. 


Tricuspid  Diseases  lOl 

'dyspnoea  and  oedema;  (4)  the  e])igastric  pulse,  and  (5;  a  previous 
(history  of  rheumatism. 

If,  then,  a  woman  under  forty  has  these  symptoms  and  in  the 
tricuspid  area  a  diastolic  murmur,  the  pitch,  quality  or  other  char- 
acters of  which  distinguish  it  from  the  mitral  murmur,  it  will  be 
safe  to  make  the  diagnosis  of  tricuspid  stenosis. 

The  prognosis  is  worse  than  in  any  other  form  of  valvular  dis- 
vease. 

In  congenital  cases  patients  seldom  live  more  than  a  few  days. 
In  acquired  cases  much  depends  on  the  condition  of  life.  A  tri- 
icuspid  lesion  that  would  prove  rapidly  fatal  in  a  working  man  may 
be  maintained  a  fairly  long  time  by  a  person  in  easy  circumstances. 
Pregnancy  is  a  dangerous  epoch  for  women. 

In  general,  the  louder  the  murmur  the  less  the  danger.  With 
considerable  stenosis  there  is  apt  to  be  a  mild  bruit.  Though  pa- 
tients rarely  attain  the  age  of  forty  years,  in  the  case  that  follows 
•seventy  was  reached : 

Case  XXVII.  Mitral  and  Tricuspid  Obstruction  with  InsuM- 
£iency:  Pulmonary  Embolism:  Pleurisy,  with  Effusion. — L.,  sev- 
enty years  old,  was  admitted  to  hospital  January  3,  1881.  On  ad- 
mission the  patient  stated  that  up  to  a  week  before  admission  he 
regarded  himself  as  well.  Then  he  suddenly  developed  dyspnoea. 
Slight  cough  and  oedema  of  legs. 

On  physical  examination  an  occasional  squeak  was  heard  in  the 
right  parasternal  hne  in  the  third  interspace.  Patient's  sputum 
streaked  with  blood.  Jugulars  enlarged,  almost  pulsating.  Heart 
sounds  at  first  indistinct.  Cardiac  dilatation.  Impulse  diffuse. 
Systolic  murmur  loudest  over  ensiform  cartilage.  Tubular  breath- 
ing. Pleuritic  effusion.  Retraction  of  soft  parts  at  third  left  inter- 
space with  inspiration. 

At  the  autopsy  the  right  pleural  cavity  was  found  full  of  serum 
and  the  left  nearly  full.  Infarctions  of  lung.  Heart  dilated  and 
weiging  23  oz.  Aortic  and  pulmonary  normal.  Right  cusp  of  mi- 
tral thickened  and  bound  down,  orifice  admitting  seven  fingers. 
Valves  of  tricuspid  thickened  and  restricted   (stenosis). 


ClIArTER  IX. 

MYOCARDIAL   AFFECTIONS. 

Bcrtin.  in  his  little  book  on  Heart  Diseases,  piiblislied  in  1821, 
made  this  quaint  remark:  "General  inflammation  of  the  substance 
of  the  lieart  is  one  of  the  maladies  about  which  there  is  the  most 
melancholv  obsc u ri t y . " ' 

Bertin.  however,  did  not  distini^uish  between  inflammatory  and 
other  diseases  of  the  heart  walls,  for  at  that  early  i)eriod  such 
distinctions  were  impossible.  His  successors,  even  down  to  the 
present  day,  have  not  wholly  relieved  us  of  this  obscurity,  larj^ely 
because  conflicting  theories  have  been  advocated  as  to  the  nature 
of  these  diseases.  For  example,  Rokitansky'  and  others  ])ut  the 
seat  of  parietal  diseases  in  the  muscle  tissue.  Hristowe-  in  the  inter- 
stitial, while  lluchard-'  as  late  as  1893  claimed  that  the  cardiac  ves- 
sels were  to  blame.  Besides,  the  relations  between  muscle  degen- 
erations or  metamorphoses  and  inflammations  have  always  been 
hazy,  while  the  clinical  ]:)henomena  at  our  disposal  have  never  been 
equal  in  amount  or  quality  to  the  pathological  data.  Again,  impor- 
tant discoveries  have  been  overlooked.  Hayem,  as  early  as  1869, 
called  attention  to  the  fatty  changes  in  the  heart  muscle  of  typhoid.* 
Germain  See''  in  1883  confirmed  these  views,  Avhile  Romberg"  in  1891, 
extending  his  investigations  into  the  condition  of  the  heart  muscle 
in  scarlatina  and  diphtheria,  found  a  granular  and  fatty  change, 
together  with  a  small-celled  infiltration  of  the  connective  tissue  and 
multiplication  of  muscle  nuclei.  Hayem's  work  has  lately  been 
confirmed  by  Dehio"  and  Bollinger.'^ 

Now  that  the  discoveries  of  Hayem  and  Romberg  have  been  rec- 
ognized, the  whole  subject  of  fatty  degeneration  of  the  heart  is 
comprehensible,  and  can  be  placed  on  a  sound  basis — the  patho- 
logical. 


'Rokitansky,  Patli.  Auat..  London.  Vol.  IV..  p.  IQI. 
'Rristowe.  Pract.  of  Med.,  London,   1876.  p.  516. 
'  Huchard,  Maladies  du  Cneur.  Paris.  1893.  p.  196. 
*  Hayem.  Arch,  de  Phys.  Norm,  et  Path..  i8(V),  IL  p.  699. 
'Germain  See.  Maladies  du  Cueur,  Paris.  1883.  p.  199. 
'Romberp.  Deiitsch.  Arch.  f.  Klin.  Med..  Rd.  48  &  49.  1891-2. 
'Dehio.  Deutsch.  Arch.  f.  Klin.  .Med.,  189S.  I.  s,   i.  62. 
'Bollinger.  Path.  Anat.,  L,  p   74,  New  "^'ork,  1898. 


Myocardial  Affections  103 

I'Jut  there  are  other  matters  which  arc  still  obscure,  and  I 
know  nothing  more  confusing  in  cardiac  j^athology  than  the  use 
made  in  text  books  and  journal  articles  of  the  term  "myocarditis." 
For  no  sufficient  reason,  I  feel  sure,  Sobernheinr'  in  1837  introduced 
it,  intending  that  it  should  be  used  to  include  all  diseases  of  the  heart 
walls,  in  lieu  of  Corvisart's'"  "carditis,"  proposed  about  twenty  years 
earlier. 

Corvisart  was  an  exceedingly  acute  physician,  indeed,  a  man  who 
made  very  important  contributions  to  cardiac  pathology,  and  there 
was  no  good  reason  for  allowing  his  word  "carditis,"  which  included 
diseases  of  the  heart  muscle,  interstitial  tissue  and  vessels,  to  be 
supplanted  by  "myocarditis,"  which,  while  it  was  intended  to  cover 
all  these  affections,  actually  referred  only  to  muscle  inflammation. 
Clinically,  also,  it  has  led  to  misunderstandings,  because  with  some 
it  has  meant  simply  fatty  degeneration  of  the  heart ;  with  others 
disease  of  the  coronary  arteries. 

Of  course,  it  is  not  to  be  denied  that  inflammation  of  the  heart 
muscles  plays  an  important  role  in  parietal  changes,  and  Rokitansky's 
contention  was  correct,  in  so  far  as  he  maintained  that  there  was  a 
myocarditis,  or  muscle  inflammation ;  but  he  was  wrong  in  holding 
that  it  had  a  preponderating  influence.  Bristowe's  and  Huchard's 
theories  are  equally  correct,  but  neither  one  of  these  authorities  ap- 
pears to  have  realized  that  most  of  the  changes  in  the  myocardium 
are  not  inflammatory  at  all ;  some  being  physiological,  like  the  hyper- 
trophy of  the  heart  in  pregnancy,  or  the  changes  of  senility ;  while 
others  are  nutritive,  that  is,  dependent  on  disordered  nutrition  or 
innervation,  and  so  forth. 

When  pathologists  differed  as  to  fundamentals,  it  was  quite 
natural  that  clinicians  should  abandon  the  pathological  classification 
and  adopt  a  symptomatic  one.  It  is  in  this  way  that  Ebstein's^^ 
insuMcientia  myocardii,  debilitas  cordis  and  myasthenia  cordis,  and 
the  "iveakened  heart"  came  into  use.  But  while  these  terms  attract 
us  by  their  simplicit}',  and  relieve  us  from  the  necessity  of  espousing 
this  or  that  pathological  theory,  they  are  essentially  unsatisfactory, 
because  they  leave  us  in  doubt  as  to  what  the  matter  reallv  is.  They 
are  also  unnecessary,  if  it  can  be  shown,  as  I  believe  is  quite  possible, 
that  a  pathological  classification  is  practicable.  And  if  this  is  pos- 
sible, it  is  the  proper  one,  as  all  should  admit.  Abandoning,  then, 
the  words  "myocarditis,"  "carditis"  or  "pancarditis,"  which  latter 

^  Sobernheim,  Diagiwsfik  d.  i.  Krankheiten.  Berlin,  1837,  s.  118. 
""  Corvisart,  Lcs  Maladies  dii  Cwiir.  Paris.  1818.  p.  64. 
"  Ebstein  &  Schwalbe's  Handbuch,  Vol.  I.  s.  729. 


►Involuntary. 


104  Myocardial  Affections 

has  been  suggested,  I  purpcise  to  show  that  the  conditions  mentioned 
are  to  be  placed  under  the  simple  heading"Myocardial  Affections," 
of  which  there  are  the  following  varieties,  viz. : 

1.  Fatty  changes  \f  pegenerations. 

(  I'.  Depositions. 

2.  Simple  hypertrophies  as  caused  by 

a.  Severe    exercise    Voluntary. 

/'.  Pregnancy. 

c.  Vascular    obstruction,    including    aneurisms 

and  atheroma. 

d.  Unusually  small  vessels ■}    •        •     j    ' 

■'  (  Acquired. 

c.  The  emotional  or  neurotic  heart.  j 

f.  The  heart  in  mechanical   injury. 

3.  Simple  dilatations  as  caused  by 

a.  Infections.* 

b.  Anaemia,  etc. 

4.  Atrophies  of  the  heart. 

*  Tubercles  are  occasionally  seen  in  the  heart  substance. 

HYPERTROPHIES  OF  THE  HEART. 

The  normal  adult  male  heart  averages  from  10  to  12  ounces; 
the  adult  female  heart  from  8  to  10;  the  size  of  the  organ 
in  health  varying  somewhat  with  the  dimensions  and  development 
of  the  body,  and  the  work  that  it  is  called  upon  to  do. 

\\'hether  in  animals  or  men,  however,  if  the  organ  is  called  on  for 
extra  work,  it  will  enlarge  in  order  to  accomplish  it.  Familiar  exam- 
ples reminding  us  of  this  truism  are  well  known.  A  horse  or  dog 
that  is  continually  forced  to  work  at  a  high  rate  of  speed  will  sooner 
or  later  develop  hypertrophy  of  the  heart,  and  may  die  of  it  suddenly, 
at  some  time  or  other.  Such  instances  are  probably  known  to  all 
of  us.  Again,  among  the  athletic  youth  of  the  present  day,  it  is  a 
regular  event  for  those  who  train  hard,  to  have  some  hypertrophy 
of  the  heart  walls  ;  so  that  it  is  to  be  expected  in  professional  boat- 
ing or  baseball  men,  and  even  in  tennis  experts.  I  have  recently 
had  under  my  care  a  case  of  hypertrophy,  due,  undoubtedly,  to  the 
strain  of  tennis  tournaments.  We  also  have  all  the'  evidence  that 
is  required,  to  show  that  professional  mountain  climbers,  and  miners 
who  have  to  climb  long  and  steep  ladders  will  very  frequently  con- 
tract hypertrophy  of  the  heart ;  though,  doubtless,  in  these  particular 
instances  there  are  other  contributing  factors,  the  mountain  climb- 
ers being  compelled  to  breathe  a  highly  rarificd  air  and  the  miners 
one  vitiated  by  coal-dust  or  smoke.  So,  in  many  other  instances, 
two  or  more  causes  of  hypertrophy  coexist. 

At  first,  the  normal  heart  dilates  under  the  strain,  but  it  contracts 


Myocardial  Affections  105 

again  when  the  strain  is  over,  and  is  usually  no  worse  for  it.  If 
the  strain  is  prolonged,  however,  the  heart  contracts  less  readily, 
and  if  the  strain  becomes  continuous,  the  walls  of  the  heart  gradually 
thicken  by  the  enlargement  of  the  muscle  bundles — perhaps  by  an 
increase  in  the  muscle  cells — until  the  organ  is  so  re-enforced  by 
additional  muscle-tissue  that  it  is  competent  to  do  the  work  it  has 
before  it.  This  new  development  of  muscular  tissue  in  the  heart, 
fitting  it  for  larger  work,  superinduces  a  condition  of  so-called 
"compensation."  But  the  demands  made  upon  the  heart,  whether 
m  the  normal  or  compensated  condition,  may  be  too  great,  and  some 
fibres  will  overstretch  or  even  break.     Hence  "heart  strain." 

The  strain  may  occur  in  the  substance  of  the  walls,  in  the  pap- 
illary muscles,  or  in  the  chordae  tending,  the  heart  dilating  suddenly 
and  having  no  pov^er  to  contract,  and  the  patient  dying  then  and 
there  with  cardiac  paralysis.  Such  an  accident  occurred  in  Case 
XXVIII.  Or,  the  patient  may  have  a  season  of  arrythymia  and  then 
recover  wholly  or  in  part,  in  which  case  he  will  have  a  permanently 
strained  heart,  "the  irritable  heart"  which  Da  Costa^-  saw  so  fre- 
quently among  soldiers. 

In  the  pregnant  woman  there  is  a  physiological  hypertrophy  of 
the  heart  that  develops  pari  passu,  I  believe  (though  it  has  been 
denied),  with  the  increase  of  the  blood  required  for  the  nourish- 
ment of  the  uterus,  its  contents  and  the  breasts ;  but  as  soon  as 
parturition  has  been  accomplished,  there  begins  at  once  a  gradual 
diminution  in  the  size  of  the  heart,  to  correspond  with  the  dimin- 
ished volume  of  blood  needed  by  the  parturient  woman.^^  Reasoning 
by  analogy,  therefore,  we  have  a  right  to  assume  that  as  the  heart 
develops  in  pregnancy  and  then  retrogrades,  a  similar  process  may 
take  place  in  the  athletic  heart;  and  this  is  probably  true,  the  en- 
larged hearts  that  remain,  as  permanent  fixtures,  in  these  men,  being 
instances  of  strain  from  which  they  have  not  altogether  recovered. 

Another  physiological  increase  in  the  heart  may  presumably 
occur  in  gluttons  or  drinkers  who  habitually  consume  more  than 
is  required  by  the  wants  of  nature,  so  that  they  create  a  surplus  of 
blood  in  the  system,  requiring  an  enlargement  of  the  heart  to  propel 
the  increased  volume  of  blood. 

There  are  many  -  varieties  of  pathological  hypertrophy,  using 
these  terms  to  mean  hypertrophy  following  lesions  of  the  organ. 

I  have  in  my  records  many  examples  of  hypertrophied  hearts, 


"Da  Costa,  Medical  Diagnosis,  Phila.,  1895,  p.  457. 

"  An  enlargement  of  the  heart  due  to  renal  disease  in  pregnancy  has  also 
been  described. 


lo6  Myocardial  Affections 

the  majority  of  thcni  hypcrtroiihics  of  tho  left  ventricle,  due 
to  defects  in  the  aortic  or  mitral  valves.  It  is  quite  common  in 
these  cases  for  the  heart  to  weigh  15  to  Jo  ounces;  and  not  very 
uncommon  to  find  it  20  or  30  ounces  ;  while  it  may  have  a  much 
greater  weight. 

Two  of  these  cases  were  due  to  artcrio-sclcrosis.  and  arc  worthy 
of  brief  notice. 

Case  XXriH.  Hypertrophy  of  the  Heart.  Arterio-selerosis. — 
One  of  these  patients,  a  i)rinter,  44  years  of  age,  entered  the  his- 
pital  with  extreme  dyspncea  and  palpitation.  Aortic  and  mi- 
tral organic  murmurs  were  noted,  with  pulsation  of  jugulars.  Pulse 
varied  from  36  to  84.  He  died  after  being  under  observation  about 
three  months,  having  developed  general  anasarca.  At  the  autopsy 
large  atheromatous  |)]atcs  were  found  in  the  aorta,  and  the  mitral 
\\as  diseased.  The  heart  was  enormously  enlarged,  chiefly  in  the 
left  ventricle,  and  the  hypertrophy  (the  heart  weighed  t^i  ounces) 
was  ascribed  to  general  arterio-selerosis.  Rupture  of  chordae  tendi- 
n.T  was  the  immediate  cause  of  death. 

Case  XXIX.  Cor.  Boi'iv.uui:  Arteriosclerosis. — In  anc^ther  case  a 
laborer,  67  years  of  age,  of  full  habit  and  robust,  but  syphilitic,  was 
admitted  to  the  hospital  January  21,  1887,  suffering  from  chronic 
diffuse  nephritis  and  uraemia.  He  lived  but  a  few  days.  At  the 
post-mortem  examination  many  signs  of  constitutional  syphilis  were 
noted,  such  as  syphilitic  meningitis  and  cirrhosis,  in  addition  to  the 
evidences  of  skin  syphilis.  On  the  heart  were  several  milk  patches, 
but  the  valves  were  free  and  sufficient,  though  slightly  marked  by 
fatty  changes.  The  hypertrophy  was  thought  to  be  due  to  the 
arterio-selerosis.  The  heart  weighed  58  ounces,  free  of  its  mem- 
branes. This  cor  hovinum  is  the  largest  I  have  known,  and  one 
ounce  heavier  than  the  famous  heart,  weighing  57  ounces,  that  was 
placed  in  the  Museum  of  the  College  of  Physicians  and  Surgeons 
of  this  city  by  the  late  Prof.  Alonzo  Clarke. 

There  is  also  a  form  of  large  heart  seen  in  hysteria  and  various 
nervous  affections,  so  that  it  might  be  called  the  neurotic  heart.  It 
is  apt  to  be  complicated  with  valvular  difficulties,  but  occasionally  we 
find  one  in  which  no  valve  lesions  are  recognizable. 

I  have  seen  such  a  case  in  Graves's  disease  when  there  was  no 
valvular  disease,  but  a  moderate  swelling  of  the  thyroid  associated 
with  tremor,  paroxysmal  tachycardia,  acute  dyspnoea,  anginoid  at- 
tacks, epigastric  pulsation,  and  obesity.  The  heart  was  very  large, 
and  the  apex  beat  was  5^  inches  from  the  median  line  to  the  left. 


Myocardial  Affections  107 

(Case  LXXV.)  This  form  of  liypertrojjliy  was  ]jrobably  compli- 
cated with  fat  deposition. 

The  tobacco  heart  is  also  apt  to  be  enlarged.  Enlargements  of 
the  right  ventricle  are  less  common  than  those  of  the  left,  but  they 
will  occur,  whenever  there  is  obstruction  to  the  pulmonary  circula- 
tion. At  various  times  a  form  of  enlarged  heart  due  to  a  congen- 
itally  small  aorta,  or  small  arteries,  has  been  described.  Morgagni'* 
wrote  of  it,  and  several  writers  have  since  then  called  attention  to 
it;  I  fancy  it  is  of  rare  occurrence.  However,  FrantzeP"'  has  given 
the  record  of  a  case  associated  with  congenital  stenosis  of  the  aorta. 
Perhaps  these  cases  are  merely  anatomical  curiosities. 

Sometimes  when  there  is  a  general  hypertrophy,  the  hyper- 
trophy of  the  right  ventricle  will  be  most  marked.  This  occurred 
in  a  case  which  I  saw  with  Dr.  W.  N.  Hubbard  of  this  city. 

Case  XXX.  Hypertrophy  and  Dilatation  of  Heart ;  Scoliosis. — 
The  patient,  an  unmarried  woman  of  middle  age,  with  scoliosis  of 
marked  type  was  taken  down  with  an  acute  attack  of  nephritis,  in 
association  with  chronic  endocarditis  and  anasarca.  At  the  post- 
mortem examination  the  heart  was  found  to  weigh  14^  ounces. 
It  was  hypertrophied  and  dilated  and  the  right  ventricle  especially 
was  thickened.  Mitral  and  aortic  valves  were  slightly  afifected. 
Hydropericardium  and  hydrothorax.  Nutmeg  liver.  In  this  case 
the  special  thickening  of  the  right  ventricle,  when  one  should  ex- 
pect the  left  to  be  most  thickened,  was  probably  due  to  the  obstruc- 
tion of  the  pulmonary  circulation,  due  to  the  deformed  and  con- 
tracted thorax. 

It  is  usually  easy  to  determine  if  a  heart  is  enlarged.  Bulging 
of  the  pericardimn,  with  or  without  pericardial  adhesions,  is  com- 
mon in  large  hearts.  On  palpation,  the  impulse  at  the  apex  is  diffuse 
and  heaving;  it  may  be  in  the  5th,  6th.  7th  or  8th  interspace;  in 
the  line  of  the  nipple,  or  up  to  three  inches  beyond  it.  In  medium 
grades  it  is  in  the  6th  space,  and  line  of  the  nipple.  Percussion 
reveals  an  increased  area  of  dulness.  Beginning  in  the  2d  inter- 
space or  over  the  3d  rib,  it  may  extend  from  one-half  inch  to  three 
inches  beyond  the  left  mammillary  line,  and  perhaps  an  inch  and  a 
half  beyond  the  right  border  of  the  sternum.  This  dull  area  is  more 
ovoid  than  in  health.  There  should  be  little  difficulty  in  determining 
by  percussion  whether  the  heart  is  enlarged,  though  it  is  impossible 
to   distinguish   between   simple  hypertrophy   and   simple   dilatation 

"  Morga.eni,  De  Sedibus  cf  Causis.  Episf..  XVTIL.  Art.  2  et  4. 
"Frgentzel.  Krankhciten  dcs  Hcrzcn,  Berlin,  1S88,  s.   151. 


loS  Myocardial  Affections 

by  percussion  alone.  If  such  a  differential  diagnosis  is  necessary,  ra- 
tional signs  nnist  be  utilized  to  settle  the  cjuestion. 

In  making-  a  diagnosis  we  nuist  carefully  dift'erentiate  from  the 
lieaving-  im[)ulse  of  i)alpitation.  Then  the  increased  area  of  dulness 
may.  it  nuist  be  remembered,  occur  in  pericarditis  with  effusion, 
aneurism,  mediastinal  tumors,  and  localized  pleurisy.  In  this  regard, 
assistance  will  be  furnished  by  calling  to  mind  that  there  are  titreg 
stages  of  hypertrophy.  In  the  first  there  is  the  period  of  dilating 
compensation,  where  there  is  an  irregular  heart  action,  increase  in 
.strength  of  pulse,  and  a  tendency  to  accentuation  of  the  second  pul- 
monar\-  sound.  When  the  hypertrophy  has  reached  the  stage  of  full 
compensation,  normal  action  in  heart  and  pulse  has  been  estab- 
lished {second  stage).  In  failing  compensation  (the  third  stage) 
we  have  increased  dilatation,  as  shown  by  a  feeble  impulse  at  the 
apex,  soft  and  irregular  pulse,  and  cardiac  distress. 

To  a  certain  extent,  hypertrophy  is  a  benign  process,  designed 
by  nature  to  relieve  another  abnormal  condition ;  and  so  long  as  the 
bodily  health  is  maintained,  and  the  work  of  the  heart  is  not  exces- 
sive, but  proportioned  to  the  strength  of  the  individual,  there  is  no 
need  for  alarm.  But  if  the  primary  disease,  be  it  valvular,  pericardial 
or  vascular,  so  increases,  that  the  heart  is  strained  in  maintaining  its 
equilibrium ;  or  the  patient  has  insufficient  nourishment,  or  is  over- 
worked, the  heart  will  dilate  (failure  of  compensation)  and  collapse 
will  ensue. 

In  directing  the  proper  course  of  treatment  these  facts  must 
always  be  borne  in  mind. 

At  this  point  it  may  be  well  to  make  a  brief  statement  about  the 
vexed  subject  of  dilatation  and  hypertrophy,  and  their  relation  to 
one  another.  The  facts,  I  take  it,  are  these :  There  is  a  close 
relation  between  the  conditions,  and  they  often  coexist  (eccentric 
hypertrophy),  but  not  always.  In  hypertrophy  there  may  or  may 
not  be  dilatation.  For  example,  in  the  early  stages  of  arterio- 
sclerosis, where  there  is  no  increase  of  the  blood,  but  more  force 
must  be  applied,  there  will  be  hypertrophy  without  dilatation  (con- 
centric hypertrophy).  In  the  enlarged  heart  of  the  beer  drinker, 
who  has  created  new  blood,  there  is  dilatation  of  the  heart  cham- 
bers, to  accommodate  the  increased  amount  of  blood  to  be  driven 
and  the  heart  hypertrophies  in  order  that  it  may  be  able  to  drive  it.  In 
dilatation,  too,  there  may  or  may  not  be  hypertrophy.  For  example, 
m  the  breaking  down  of  compensation  in  the  hypertrophic  heart 
there  will  be  dilatation,  but  in  the  dilated  heart  of  accidental  strain 


Myocardial  Affections  109 

to  a  healthy  heart  there  will  be  no  hypertrophy.  A  similar  dila- 
tation without  hypertrophy  will  occur  in  the  stage  of  softening  of 
the  heart  which  attends  and  follows  the  toxaemias,  such  as  typhoid, 
etc.  Acute  dilatation  often  occurs  probably  after  prolonged  strain, 
as  in  bicycle  riding,  "running,  etc, 

At  post-mortem  examinations  this  condition  may  be  deceptive,  and 
the  apparent  encroachment  on  the  chambers  in  concentric  hyper- 
trophy may  be  due  to  the  fact  that  the  patient  died  while  the  heart 
was  in  extreme  systole.  So,  on  the  other  hand,  appearances  may 
be  equally  deceptive  as  to  dilatation  of  the  heart,  which  may  be  be- 
cause the  patient  died  when  the  cavities  were  dilated  in  diastole,  or 
because  of  changes  in  the  substance  of  the  cardiac  muscles,  due  to 
post-mortem  relaxation.  Owing  to  these  circumstances,  the  rela- 
tion of  dilatation  to  hypertrophy  is  often  a  difficult  matter  to  decide, 
even  at  a  post-mortem  examination. 

Atrophy  of  the  heart  is  less  common  than  hypertrophy.  It  may 
be  a  family  peculiarit}^  or  it  may  be  due  to  arrest  of  development, 
or  it  may  be  acquired ;  or  the  result  of  the  physiological  changes  of 
senility. 

Church  has  recorded  the  case  of  an  adult,  aged  47,  where  the 
heart  weighed  only  3  oz.,  i  dr.,  while  Bramwell  saw  one  weighing 
only  2  oz.,  12  dr.,  ii  grains  in  a  woman,  the  mother  of  several  chil- 
dren {BramzveU's  Dis.  of  the  Heart,  N.  Y.,  1884,  p.  631).  There 
may  be  total  or  partial  atrophy.  When  people  die  of  starvation 
or  of  extreme  old  age  the  heart  is  apt  to  be  atrophied,  but  atrophy 
may  result  from  arteriosclerosis,  phthisis,  cancer,  diabetes,  or  in 
fact,  any  wasting  disease.  In  many  of  these  cases,  especially  in 
death  from  starvation  or  wasting  diseases,  the  heart  is  apt  to  have 
a  brown  color.  (Brozvn  atrophy.)  There  is  also  a  special  variety 
of  the  small  heart  described  by  Virchow  as  associated  with  the 
small  vessels  of  anaemia.  He  called  it  hypoplasia  cordis.  But  a 
heart  may  be  atrophied  as  to  its  muscle  elements,  and  still  be  large, 
for  the  affection  may  be  associated  with  a  fat  deposit.  In  some 
instances  of  atrophy  of  the  heart  the  organ  is  so  shrunken  that  the 
tortuous  vessels  stand  out  in  relief  on  the  surface,  while  the  whole 
surface  is  thrown  into  folds.  This  variety  has  been  called  the 
"zvithered  apple  heart."  Bramwell  has  a  good  plate  of  it.  On 
microscopic  examination  the  muscle  elements  are  found  to  be  shriv- 
elled, and  yellow  granules  or  pigment  are  disponed  around  the  nuclei 
and  drawn  out  in  a  line  with  the  fibres.  While  there  are  the  usual 
signs  of  cardiac  disease  in  the  atrophied  heart,  there  are  none  which 


no  Myocardial  Affections 

are  distinctive,  except  that  the  heart  may  sometimes  have  a  smaller 
area  of  duhiess  than  usual,  with  the  impulse  nearer  the  median  line 
and  higher  up  than  normal.  The  other  symptoms  common  to  atrophy 
and  other  forms  of  cariliae  diser.se  are  turns  of  fainting-,  spots  he- 
fore  the  eyes,  singing  in  the  ears,  irregular  pulse,  palpitation.  i)re- 
cardial  distress,  confusion  ol  mind.  Tlie  ti>lli'\ving  ease  is  an  exam- 
ple taken  from  my  records: 

Case  XXXI.  .Ifrof^liy  of  the  Heart:  Carcinoma. — A  working 
man  of  59.  anaemic  and  cachectic  in  apjjcarance,  entered  the  hospital 
in  1884.  and  after  a  stay  of  about  nine  months,  died  of  progressive 
emaciation  ( and  in  part  starvation ) .  due  to  primary  carcinoma  of 
the  omentum,  and  secondary  implication  of  the  mesenteric  glands, 
liver  and  kidneys.  The  heart  was  found  small,  soft  and  fatty.  It 
weighed  only  8  oz. 

Case  XXXII. — Another  case  on  my  records  occurred  in  the 
practice  of  Dr.  R.  E.  \'an  Giesen  of  Greenpoint,  and  illustrates  the 
atrophy  that  sometimes  is  found  in  sarcoma.  The  pleura  and  medi- 
astinum were  involved  in  a  sarcomatous  growth.  The  pericardium 
varied  from  3^  inch  to  1  ^4  inches  in  thickness,  and  the  inner  sur- 
face was  hairy.  The  heart  weighed  not  more  than  5  oz.  The 
I)atient  was  22  years  of  age  and  well  developed,  and  the  body  was 
well  nourished. 

Arteriosclerosis  is  well  seen  in  the  gouty  kidney  and  in  the 
physiological  changes  incidental  to  old  age.  There  is  a  degeneration 
of  the  cell  elements  of  the  capillaries  and  smaller  vessels,  the  proto- 
plasm undergoing  what  is  know^n  as  hyaline,  then  fatty,  and  later, 
atheromatous  change.  lUit  as  I  have  intimated,  the  hard  pulse  of 
old  age  may  be  regarded  as  physiological.  The  causes,  as  far  as 
we  know,  are  syphilis,  alcoholism.  IJright's  disease,  hard  work,  dia- 
betes, gout,  lead  poisoning  and  emotional  conditions.  The  changes 
produced  in  the  w^alls  of  the  vessels  are  caused  by  the  toxins  carried 
by  the  blood  vessels.  Xature,  however,  comes  to  the  assistance  of 
the  individual  whose  vessels  are  so  thickened  by  disease,  and  the 
left  heart  h}pertrophies  in  order  to  compensate  for  the  increased 
work  it  has  to  do  in  driving  the  requisite  amount  of  blood  through 
the  thickened  and  tortuous  vessels.  The  old  theory  that  the  arteries 
are  thickened  by  the  blood  forced  against  the  walls  of  the  vessels  is 
now  maintained  by  few  pathologists. 

When  arteriosclerosis  attacks  the  coronary  vessels  of  the  heart 
we  encounter  a  special  phase  of  the  malady.  The  coronary  arteries 
are  terminal,  like  those  of  the  brain  and  kidneys  ;  that  is,  they  do  not 


Myocardial  Affections  1 1 1 

anastomose  with  their  fellows,  so  that  any  occlusion  of  a  coronary 
artery,  whatever  its  degree,  diminishes  proportionately  the  vascular 
supply  within  the  area  of  its  distribution,  while  the  nutrition  of  the 
heart  wall  is  correspondingly  afifected. 

When  such  an  area  has  been  deprived  of  its  blood  the  jjarl  un- 
dergoes what  has  been  called  "ancemic  necrosis,"  a  condition  that 
was  formerly  known  as  inyoiiialacia  cordis.  This  starved  area  has 
been  called  a  zvliite  infarct.  Whatever  the  result  of  the  process, 
the  heart  wall  is  left,  of  course,  unsound.  The  result  of  a  healed 
white  infarct  is  a  fibroid  area,  due  to  the  deposit  of  fibrin  as  a  substi- 
tute for  the  dead  tissue.     Such  a  heart  would  also  be  called  sclerotic. 

Sclerosis  may  lead  to  cardiac  aneurism,  the  sclerotic  or  fibroid 
tissue  yielding  under  the  contractions  of  the  organ  so  that  the  heart 
w^alls  bag  out. 

It  is  claimed  that  embolism,  or  even  thrombosis,  in  a  coro- 
nary artery  will  produce  sudden  death.  I  have  never  seen  such  an 
instance,  however;  and  it  would  be  very  difiicult,  I  fancy,  if  not  im- 
possible, to  prove  it. 

Abscesses  of  the  heart  occur,  but  are  extremely  rare. 

In  misplaced  hearts,  the  statements  of  Bouvier,^^  Adams^'  and 
Bradford^**  that  heart  affections  are  superinduced  by  deformities 
of  the  vertebrae  have  found  support  in  the  experiments  of  Neidert,^'' 
who,  in  31  cases  of  Pott's  disease  and  lateral  curvature,  found  that 
most  of  the  bad  cases  died  earty  of  heart  failure.  Spinal  deformities 
cause  mechanical  embarrassment  to  the  circulation,  leading  at  first 
to  hypertrophy,  possibly  to  distortion  of  the  valves,  and  eventually 
to  heart  failure.-" 


^^  Bouvier,  Legons  C Uniques,  Paris,  1858.  p.  145. 
"Adams,  Curvature  of  the  Spine,  London,  1882. 
^*  Bradford,  Orthopccdic  Surgery.  1890.  p.  14.. 

"  Neidert,  Inaug.  Diss.,  Munich;  1883,  V.  &  H..,  Jahrb,  1886,  s.  371. 
^Displacements   of  the   Heart   in   Lateral   Curvature,  A^    V.   Med.   Jour., 
Sept.  30,   1899. 


Chapter  X. 

THE    FAT    HEART. 

Corpulence  and  the  fat  heart  are  so  closely  related  that  a  con- 
sideration of  one  involves  the  other.  Chambers  found  that  in  thirty- 
six  corpulent  people  twelve  had  the  fat  heart,  while  Quain's  obser- 
vations were  that  patients  with  fat  hearts  were  invariably  corpulent. 
\\c  may  infer,  therefore,  that  corpulence  disposes  to  fat  heart.  Prob- 
ably the  one  is  essential  to  the  other.  The  term  fat  heart  means 
nierel\-  that  the  heart  is  burdened  by  an  excessive  deposit  of  fat ; 
not  that  it  has  undergone  fatty  degeneration.  The  fat  heart  is  said 
to  be  in  a  condition  of  infiltration,  pathologically  speaking.  Fatty 
degeneration  of  the  heart  is  a  more  dangerous  affection,  but  it  may 
be  a  sequel  to  fat  infiltration.  If  they  coexist,  which  sometimes 
happens,  the  prognosis  is  vastly  w'orse. 

Corpitloicc  or  obesity  consists  in  an  excessive  deposit  of  adipose 
tissue  in  parts  of  the  body  which  are  comparatively  free  from  fat 
in  health.  It  is  caused  essentially  by  nutritive  disturbances ;  or  to 
put  it  in  another  way,  it  is  the  result  of  a  loss  of  the  equilibrium  be- 
tween assimilation  and  disassimilation. 

Obesity  is  a  serious  matter  in  many  ways.  First  of  all,  it  is  a 
positive  discomfort  to  the  patient,  for  locomotion  is  made  difficult, 
digestion  is  disturbed,  and  the  faculties  are  often  dulled.  Obese 
people,  too,  have  a  constant  tendency  to  constitutional  disorders, 
such  as  gout,  rheumatism  and  diabetes.  There  is  also  the  ever- 
present  danger  of  some  serious  illness,  accident,  or  surgical  opera- 
tion, which  they  may  not  be  able  to  survive ;  as  corpulent  people  are 
deficient  in  vital  power.  Fat  infants  and  children,  in  my  experience, 
seldom  reach  adult  life,  w^hile  in  advancing  years  the  obese  may 
be  totally  unable  to  go  about.  I\Iiles  Darden,  whose  height  was 
seven  feet  six  inches,  and  who  weighed  over  a  thousand  pounds,  had 
to  be  transported  in  a  wagon  during  the  last  four  years  of  his  life. 
Corpulence  may  be  a  disturbing  factor  in  social  life.  It  is  said  that 
in  Albania,  corpulence,  in  the  male,  is  a  proper  ground  for  divorce. 

Excessive  weight  has  been  treated  successfully  from  very  early 
times,  the  Greeks  employing  trained  men  to  reduce  their  athletes, 
but  corpulence,  as  a  disease,  was  not  plainly  shown  until  the  present 
century,  when  English  physicians,  such  as  Wadd  (in  1825),  Cham- 


The  Fat  Heart  J 13 

bers  (in  1850),  R  liarvcy  (in  1864J,  and  (Juain  (in  1880-1885), 
wrote  up  tlie  subject.  Harvey  was  the  physician  of  IJanting,  and  his 
method,  known  as  the  I  Wanting  system,  Ijecame  widely  known  and 
was  extensively  practiced. 

Adipose  tissue  is  chiefly  stored  in  the  subcutaneous  connective 
tissue  beneath  the  serous  membranes  or  in  the  inter-muscular  septa. 
The  largest  deposits  are  beneath  the  skin  of  the  abdomen,  in  the 
mesentcr}-,  in  the  buttocks  and  thighs,  and  in  the  back  of  the  neck. 
In  women  the  excess  of  fat  is  usually  in  the  thighs  and  buttocks. 
,\  certain  amount  of  fat  is  normally  contained  in  the  connective 
tissue  corpuscles,  in  the  form  of  minute  specks.  According  to 
Michael  Foster,  these  specks  coalesce  mto  droplets,  these  again  into 
drops,  until,  as  the  protoplasm  of  the  corpuscles  diminishes  and  the 
oil  globules  vmite,  the  original  connective  tissue  corpuscle  is  con- 
verted into  a  fat  cell.  The  remnant  of  the  protoplasm  is  then 
gathered  about  the  nucleus.  To  a  moderate  extent,  fat  tissue  is 
natural,  as  it  is  a  normal  constituent  of  the  system  ;  and  within 
physiological  lines  ordinary  fat  tissue  may  be  increased  so  as  to  sub- 
serve a  useful  purpose,  constituting  a  reserve  store  upon  which  the 
body  may  draw  for  nutriment  in  periods  of  prolonged  vital  strain. 

But  obesity  has  a  progressive  tendency,  for  as  the  bodily  weight 
increases,  and  with  it  the  dyspnoea  and  palpitation  which  necessarily 
follow  exertion,  there  is  a  further  hindrance  to  the  oxidation  of  the 
blood,  which  is  still  more  increased,  when  the  heart  becomes  involved 
in  the  fatty  process.  Corpulence  also  begets  plethora,  and  it  in 
turn  hemorrhoids,  varicose  veins,  haemorrhages,  vertigo,  headache, 
disturbances  of  sight  and  hearing,  dulness  of  the  intellect  and  dys- 
pepsia ;  all  of  which  may  be  attributable  to  passive  congestions.  It 
must  not  be  supposed,  however,  that  all  corpulent  people  are  so 
afifected.  Sam  Johnson,  the  author  of  Rasselas,  and  David  Hume, 
the  historian,  were  corpulent,  but  led,  for  the  most  part,  in- 
tensely active,  intellectual  lives,  notwithstanding  this  malady. 

Obesity  may  occur  at  all  ages.  I  have  seen  it  in  infants  under 
one  year.  In  a  number  of  cases  I  have  ascribed  it  to  a  surfeit  from 
artificial  feeding  with  food  containing  too  much  cream,  or  a  super- 
abundance of  starchy  material.  In  two  instances  (see  Cases  XXXIII 
and  XXXIV)  the  deficient  oxidation  of  the  tissues  is  shown  by  dim- 
inution in  their  normal  percentage  of  urea.  Both  of  these  patients 
were  lithgemic.  as  the  diminution  in  the  excretions  of  urea  would 
mdicate.  Lack  of  active  exercise,  too  much  sleep,  and  a  secluded 
life  also  tend  to  corpulence.      The  obesity  of  some  women  of  the 


114  The  Fat  Heart 

East  is  explained  by  Charles  Robin  c)n  the  groiuul  that  the_\-  take 
little  exercise,  eat  all  day  long-,  and  sleep  a  great  deal.  Obesity  is 
also  hereditary,  while  races  living  in  a  low.  cool  and  moist  climate 
are  especially  prone  to  it.  Drinking  any  liqnid  in  excess  also  in- 
duces corpulence.  Fermented  li(|nors  and  the  alcoholics  are  special 
causes.  Overeating  may  likewise  cause  it.  Most  persons  eat  more 
than  is  good  for  them.  Persons  who  drink  water  in  excessive 
quantities  are  usually  corpulent,  especially  if  the\-  drink  much  at 
their  meals  ;  perhaps  Ix'cause  the  increased  amount  of  water  inter- 
feres with  digestion  and  assimilation.  IJesides,  if  the  gastric  juice 
is  (.Hinted,  the  blood  is  made  more  li(|uid.  and  the  red  corpuscles  are 
in  a  measure  dissolved. 

Fat  tissue  ai^pears  to  be  chiefly  formed  both  from  the  carbo-hy- 
drates, and  also  from  the  sur])lus  carbon  of  the  proteids  or  albu- 
minoids ;  from  i)ure  fat  taken  as  food  :  and  from  water  or  other 
liquids.  Some  authors  hold,  however,  that  fat  taken  as  food  does  not 
make  fat  tissue.  Ebstein,  of  Goettingen,  maintains  this  view.  The 
truth  ap])cars  to  be  that  when  fat  (or  an  albuminoid)  is  eaten  in 
small  quantity,  no  fat  is  stored  up ;  but  when  the  fatty  food  or  allju- 
ininoids  are  increased  to  a  point  where  the  carbon  is  no  longer 
l:)urned.  it  is  retained  in  the  system  as  fat. 

W'e  are  not  very  fully  informed  as  to  the  pathological  findings  in 
the  corpulent  after  death.  I,  myself,  never  gave  the  matter  much 
attention,  although  I  liave  made  a  good  many  post-mortems  on  cor- 
pulent people.  P.ut  after  death,  the  tissues  of  the  cor]>ulent  are  apt 
to  be  soft  and  flaccid,  and  decomposition  rapidly  ensues.  In  a  case 
of  fat  heart  occurring  in  my  pathological  service  in  St.  Luke's  Hospi- 
tal, where  death  was  sudden  in  a  man  only  thirty-three  years  of  age, 
the  left  ventricle  was  found  hypertrophied  ;  there  was  oedema  of  the 
lungs ;  the  spleen  was  large  and  soft ;  the  liver  fatty ;  while  the 
liver,  kidneys,  and  portions  of  the  stomach  were  congested. 

The  diagnosis  of  corpulence  is  simple,  but  it  is  generally  ad- 
mitted that  the  presence  of  a  fat  heart  cannot  be  positively  deter- 
mined by  physical  signs.  It  is  a  matter  of  inference.  But  most  agree 
with  Quain,  that  where  the  pulse  is  small  and  weak,  the  first  sound 
of  the  heart  feeble,  the  impulse  weak  and  the  heart's  area  enlarged 
in  a  patient  who  is  corpulent,  it  may  be  pretty  certain  that  there  is 
a  fat  heart.  Henry  Kennedy,  of  Dublin,  in  opposition  to  Quain, 
based  his  diagnosis  on  a  large,  full  pulse,  not  increased  in  frequency, 
an  enlarged  area  of  heart  dulness.  and  possibly  a  soft  systolic  mur- 
nuir  over  the  aorta,  with  the  first  sound.     In  my  experience  a  fat 


The  Fat  Heart  115 

heart  is  often  accompanied  by  valvular  lesions,  and  1  think  that  my 
experience  will  be  found  borne  out  by  a  study  of  rejjorted  cases. 
Hence  it  is  that  Kennedy  may,  in  his  cases,  have  found  a  full  pulse 
which  was  due  to  valvular  lesions.  In  this  connection,  however,  I 
■ong-ht  to  say  that  during-  the  treatment  for  fat  heart  previous  mur- 
murs will  sometimes  disappear,  a  fact  indicating'  to  my  minrl 
that  these  ])articular  murmurs  were  probably  due  to  a  relaxed  con- 
dition of  the  heart  chambers  or  ostia,  and  not  to  an  organic  valvular 
■disease. 

Obesity  is  a  disease  that  can  be  successfully  treated  in  most 
cases,  if  the  patient  has  a  fair  amount  of  vitality  ;  and  even  in  the 
feeble,  the  dangers  attendant  on  a  scientific  course  of  treatment  are 
small  as  compared  with  the  risks  in  neglecting  it.  According  to 
Maccary,  as  quoted  by  Worthington  in  his  excellent  These  de  Paris 
(1875).  the  methods  of  the  ancients  comprised  venesection,  the  use 
■of  purgatives,  exercises,  friction,  diet,  and  stimulation  of  the  several 
emunctories  of  the  system.  These  methods,  however,  were  prob- 
ably not  applied  to  the  very  young,  the  very  old  or  the  feeble.  It 
seems  hardly  worth  while  to  discuss  the  topic  of  venesection.  Drugs, 
however,  are  still  very  extensively  used.  Liquor  pofassae  was  rec- 
ommended by  Chambers  in  1850.  The  dose  was  from  one-half 
drachm  to  one  and  one-half  drachms.  The  theory  of  the  action  of 
this  drug  is,  that  "it  increases  the  vital  power  of  metamorphosis  by 
saponifying,  in  part,  the  fat  contained  in  the  blood,  enabling  it  to  be 
burned  ofif  as  carbonic  acid.^  It  is  no  longer  used.  Probablv  no 
stomach  could  stand  its  administration  for  any  length  of  time.  Its 
■effect,  if  any,  was  to  prevent  digestion.  In  other  words,  it  was  one 
of  the  many  "starvation  cures." 

Fowler  s  solution,  in  five  minim  doses  three  times  a  day.  has  been 
used.  I  have  known  it  to  be  tried,  but  never  with  success.  It  is 
imcertain  in  action,  and  may  increase  the  weight. 

Fnciis  vesicidosus,  or  bladder  w^rack.  a  species  of  seaweed  found 
in  the  Atlantic  Ocean,  w^as  at  one  time  used,  on  account  of  the  iodine 
and  bromine  it  contains.  It  was  given  in  a  decoction  of  two  to 
four  drachms  to  the  ounce.  The  taste  is  very  offensive  and  the 
stomach  is  greatly  irritated,  so  that  gastric  catarrh  may  be  produced. 
The  kidneys,  however,  are  urged  to  great  activity.  Some  have 
simplified  this  latter  method  by  giving  tincture  of  iodine  in  doses 
■of  two  to  four  drops  in  a  wineglass  with  lemon  juice ;  but  this  treat- 
ment also  seems  to  produce  catarrh  of  the  stomach. 

'  U.  S.  Dispensatory.  1880,  p.  862. 


ii6  The  Fat  Heart 

Bromide  of  aiiiiinniiiiiii  in  doses  of  five  to  thirty  grains  per 
day  lias  been  roconunciidcd.  It  is  unpleasant  to  the  taste  and  irri- 
tating to  the  system  in  many  ways.  In  line  with  this  is  the  treat- 
ment b}-  vmegar.  It  reduces  the  tiesh,  but  produces  nervous  dis- 
turbances. According  to  llrillat-Savarin  ( W'orthington  ) .  it  caused 
the  death  of  a  }e)uiig  girl  of  eighteen  who  in>isted  on  taking  a  wine- 
glassful  every  tlay. 

The  Banting  method  was  at  one  time  widely  employed,  lianting 
had  trietl  the  waters  of  Leamington,  Llieltenham  and  Harrogate; 
had  taken  plenty  of  outdoor  exercise  of  a  vigorous  kind  ;  had  tried 
Turkish  and  vapor  baths,  and  had  used  liquor  potassae  as  reconi- 
meiuled  by  Chambers,  but  with  no  eliect.  Mis  physician.  Dr.  F. 
]  larvey.  then  ])ut  him  on  a  regular  diet  that  consisted  of  four  meals 
a  day.  lie  took  eleven  to  fourteen  ounces  of  meat.  game,  poultry 
or  hsh  (pork  ami  salmon  excepted),  tea  without  sugar,  rusks  and 
toast  in  small  quantity  all  vegetables  except  potato  ;  four  to  seven 
glasses  of  claret  and  two  to  three  ounces  of  fruit.  Hot  drinks  of 
"grog"  at  night.  lie  is  said,  how'ever.  to  have  also  been  ordered 
a  mysterious  black  draught  on  rising,  the  ingredients  of  which 
I  have  not  been  able  to  discover.  On  this  system,  kept  up  for  some- 
thing over  a  year,  he  fell  off  from  202  to  156  pounds,  losing  46,  or 
at  the  rate  of  3  to  4  per  month.  The  case,  as  described  by  the 
patient,  is  somewhat  lacking  in  details  from  a  medical  point  of  view. 
The  loss  of  weight  ])er  month  was  rather  small — and  the  dietary, 
especially  as  to  alcoholics,  was,  to  say  the  least,  liberal. 

The  permanganate  of  potassium  in  doses  of  one-fourth  to  one 
grain  before  meals  has  been  recommended  by  Bartholow.  It  is  said, 
at  any  rate,  to  relieve  the  acute  gaseous  dyspepsia  of  the  corpulent. 

CJiambers'  system  consisted  in  a  diet  of  two  meals  each  day, 
active  exercises,  rubbing,  salt  baths,  alkalies  such  as  liquor  po- 
tassae in  doses  of  one-half  drachm  to  one  and  a  half  drachms,  purga- 
tives, and  even  bleeding. 

The  treatment  at  the  baths  of  Marienbad,  Taras])  and 
Carlsbad  is  due  to  the  use  of  Glauber's  salt,  which  reduces  bv  caus- 
ing watery  discharges :  but  it  is  apt  to  be  so  violent  in  its  action, 
owing  to  the  very  short  time  allowed  for  the  treatment  given,  that  it 
may  cause  flebility.  palpitation,  and  even  chronic  diarrhoea. 

According  to  Worthington,  Trousseau's  plan  was  to  allow  his 
patient  lean  meat,  fresh  vegetables  and  fruit  in  their  seasons,  but  to 
forbid  him  fat  meat,  butter,  oil  and  milk.  The  amount  of  bread 
and  milk  taken  daily  was  to  be  diminished  to  a  point  as  low  as  his 
vitality  permitted.     The  patient  was  to  be  weighed  every  two  weeks. 


The  Fat  Heart  .  iij 

and  he  was  expected  to  lose  at  the  rate  of  one  and  onc-lialf  to  three 
pounds  per  week.  Exercises  in  the  open  air  on  foot  or  on  horse- 
back were  ordered.  In  addition,  he  prescribed  baths  containing 
five  to  six  otmces  of  the  bicarl^cjnate  of  soda.  The  same  drug  was 
given  internally  to  the  extent  of  thirty  grains  per  day. 

The  pkui  pursued  by  Ebstein,  of  Goettingen,  is  about  as  follows, 
the  rules  being  modified  somewhat  according  to  the  case : 

1.  Breakfast — ^:30  A.  M.  in  summer  and  7:30  in  winter.  Large 
cup  of  black  tea  without  milk  or  sugar.  Two  ounces  of  white  or 
brown  bread.     Plenty  of  butter. 

2.  Dinner. — 2  P.  M.  Soup ;  four  to  six  ounces  of  meat,  with  fat 
gravy ;  plenty  of  vegetables  of  all  kinds  excepting  beets,  carrots, 
turnips  and  potatoes.  A  little  sweet  fruit  after  dinner.  Salad  or 
stewed  fruit.  No  sugar.  Two  or  three  glasses  of  light  white  wine. 
After  dinner  a  large  cup  of  black  tea.     No  milk  or  sugar. 

3.  Supper. — 7  P.  M.  A  cup  of  tea.  One  Qgg,  ham  fat — in  fact, 
any  fat  meat ;  sausage,  smoked  or  fresh  fish.  Two  ounces  of  white 
bread ;  plenty  of  butter.  Perhaps  a  little  cheese ;  a  little  fresh  fruit. 
This  diet  to  be  kept  up  indefinitely. 

Ebstein,  as  I  have  already  stated,  holds  to  an  idea,  opposed  by 
most,  that  the  eating  of  fat  does  not  produce  fat. 

Ocrtel,  of  Munich,  had  a  somewdiat  similar  plan,  but  prescribed 
a  peculiar  course  of  exercises,  and  sometimes  resorted  to  violent 
diaphoretics.  Pie  restricted  the  amount  of  liquids  and  solids,  limited 
carbohydrates  and  fats,  ordered  prolonged  walks,  increasing 
the  distances  daily,  making  his  patient  ascend  greater  and 
greater  heights  {Terrain  cur).  In  the  winter,  or  wdienever  his 
Terrain  cur  was  impracticable,  he  used  injections  of  the  hy- 
drochlorate  of  pilo-carpine  in  doses  of  one-third  to  one-fourth  grains 
twice  a  week. 

His  dietary  was  as  follows : 

Morning — Tea  or  coffee,  four  ounces  with  milk  and  sugar. 
Bread,  two  ounces  (roll). 

Mid-day — Beef,  ten  to  twelve  ounces  ;  an  egg.  Vegetables,  two 
to  three  ounces.  Farinaceous  food,  one  to  five  ounces.  Fruit, 
three  to  four  ounces.  Salad,  two  ounces.  Austrian  red  wine,  three 
to  four  ounces. 

Afternoon — CofTee,  four  ounces,  with  milk  and  sugar. 

Evening — One  to  two  boiled  eggs,  five  ounces  of  meat  or  six 
ounces  of  game  or  fowl ;  one  to  two  ounces  of  bread  ;  salad :  two  to 
ten  ounces  of  wine ;  Moselle  preferred.  ^ 

Among  the  newer  remedies  that  have  been  used  in  this  countrv 


ii8  The  Fat  Heart 

is  pli\toliiu\  the  active  principle  of  the  i)h}tohicca  ilecaiulra  or  poke- 
berry,  wliich  if  taken  in  ten-drop  doses  before  and  after  meals,  is 
said  to  rechice  without  dieting,  and  at  the  rate  of  five  to  twenty 
pounds  per  month.  The  drug  apparently  acts  on  the  subcutaneous 
fat,  causing  its  absorption. 

Tlwroid  extract  is  also  extensively  used.  It  produces  ema- 
ciation, but  is  often  poorly  borne  by  the  stomach,  and  is  apt  to  be 
depressing.  In  one  of  my  cases  with  hereditary  ataxia  it  greatly 
aggravatetl  the  ataxic  symptoms.  The  i^rapc  cure  is  another  means 
of  reducing  tlesh.  The  patient  is  restricted  to  unfermented  grape 
juice  for  several  weeks.  At  tirst  he  takes  it  in  excessive  quan- 
tities, then  the  amount  is  gradually  reduced  to  the  least  amount 
comi)atible  with  vitality.  Then  it  is  slowly  increased  until  enough 
is  taken  to  fairly  sustain  the  bodily  activities.  It  is  merely 
a  sort  of  "starvation  cure."  The  teas  which  are  now  widely  ad- 
vertised, but  whose  ingredients  are  not  generally  known  to  the 
jniblic.  are  chieHy  composed  of  senna  leaves,  with  a  varying  quantity 
of  chelonia.  couch  grass  and  coriander  seed.  To  be  effective  the 
dose  should  be  sufficient  to  produce  two  or  more  very  watery  move- 
ments daily. 

Dancel.  the  French  surgeon,  who  with  Trousseau  wrote  a  treatise 
on  obesity,  used  the  hydrogogue  scammony  (the  activity  of  scam- 
mony  is  due  to  its  resin),  of  which  the  dose  is  five  to  ten  grains. 
At  the  same  time  he  reduced  the  quantity  of  food  and  drink. 

There  are  many  baths  in  Europe  that  are  resorted  to  for  the 
cure  of  corpulence.  First  in  order  of  repute  are  the  cold  Glauber's 
salt  waters  of  Alarienbad,  in  Austria,  and  Tarasp  in  the  Engadine. 
But  if  patients  have  cardiac  difficulty,  asthma  or  diarrhoea,  the  hot 
Glauber's  salt  waters  of  Carlsbad  are  better :  or  the  hot  alkaline  mu- 
riatic waters  of  Ems ;  the  bicarbonate  of  soda  waters  of  Vichy,  in 
France :  or  the  alkaline-saline  of  Brides  in  France,  on  the  Italian 
frontier.  Tn  mild  cases  patients  are  usuall\-  sent  to  take  the  saline 
waters  of  Kissingen  or  Homburg.  but  even  these  latter  may  prove 
to  be  too  strong.  Some  years  ago  I  had  a  patient  weighing  220 
pounds  under  my  charge,  who  lost  fifty  pounds'  weight  at  Kissingen, 
but  his  nervous  system  was  so  deranged  that  he  told  me  he  had 
felt  "as  if  he  would  lose  his  mind.'' 

In  fact,  any  effort  to  reduce  the  weight  too  rapidly,  as  is  often 
done  at  the  Continental  spas,  is  apt  to  be  harmful.  It  is  not  desir- 
able to  lose  flesh  in  this  way ;  nor  is  it  always  well  to  reduce  the 
weight  to  the  standard  shown  by  our  American  tables.     It  is  true 


The  Fat  Heart  119 

thai  professional  trainers  can  do  it,  Init  they  usually  have  little  weic^ht 
to  take  off,  and  the  suhjects  are  men  of  exceptional  vif<or  and 
physique.  It  is  said  that  \)c  Graefe,  in  1820,  reducerl  a  butcher 
from  306  to  150  pounds  in  nine  months,  but  the  man  was  a  pugilist. 
Corpulent  people  should  not  be  treated  in  this  way. 

The  object  in  reduction  methods  is  to  take  off  the  weight  so 
that  patients  are  relieved  from  disturbances  attendant  on  the  malady 
by  means  least  calculated  to  disturb  their  equilibrium.  There  should 
be  nothing  disagreeable  about  such  a  reduction  course.  On  the 
contrary  the  patients  should  enjoy  it,  and  feel  as  each  day  or 
week  passes  by,  that  they  are  gradually  returning  to  their  normal 
state,  and  that  their  faculties  are  growing  to  be  keener  for  the 
rational  enjoyments  of  life.  It  is  best  to  let  it  be  known,  at  first, 
that  the  course  may  be  a  long  one,  lasting  months,  perhaps  even 
a  year  or  more.  Banting's  course  took  over  a  year.  The  patient 
should  be  mainly  restricted  as  to  foods  that  contain  sugar,  starches 
^nd  fats,  for  there  can  be  no  question  that  fat  to  some  extent  pro- 
duces fat.  Oxidation  should  be  increased  by  resistance  exercises 
daily,  and  by  baths  that  stimulate  the  skin,  and  so  improve  the  circu- 
lation. Enough  water  should  be  taken  to  bring  the  urea  up  to  the 
normal  amount  excreted :  no  more  is  necessary.  Tea  and  coffee 
should  be  taken,  if  at  all.  in  moderation,  because  they  seem  to  retard 
oxidation.  Acid  fruits  and  drinks  should  be  taken  sparingly,  because 
an  excess  of  them  produces  indigestion.  Sometimes  all  fruit  should 
be  forbidden.  In  general,  however,  small  fruits  may  be  taken  with 
discretion,  in  their  season.  Sometimes  the  amount  of  both  liquids 
and  solids  has  to  be  much  reduced.  Laxatives  should  be  taken,  if 
necessary,  so  to  produce  full  faecal  movements  daily ;  and  stomachics, 
if  indigestion  is  acute.  But  the  vitality  of  the  patient  should  never 
be  reduced.  It  should  constantly  increase.  A  patient  under  proper 
treatment  may  be  made  to  lose  from  four  to  ten  pounds  per  month, 
without  disagreeable  sensations  of  any  kind. 

The  following  are  illustrative  cases : 

Case  XXXIII.  Corpulence ;  Fat  Heart;  Aortic  Obstructive 
and  Mitral  Regurgitant  Murmurs;  Oedema  of  Extremities. — The 
patient,  a  physician,  76,  weight  357  pounds,  had  been  corpulent  for 
many  years  and  had  suffered  from  acute  rheumatism,  and  chronic 
eczema  of  the  low^er  extremities.  For  several  months  his  health  had 
been  failing ;  he  vfas  having  constantly  increasing  dyspnoea,  and  he 
was' unable  to  carry  his  great  weight.  He  was  Avearing  rubber  band- 
ages for  his  eczema  and  taking  arseniate  of  soda  and  Arkansas  Lithia 


I20  The  Fat  Heart 

water.  Pulse  feeble  and  intermittent,  usuall\-  absent  in  the  left  wrist. 
Impulse  at  the  apex  barely  appreciable.  Oedema  of  the  extremities. 
The  patient  was  also  taking  tincture  of  digitalis,  in  ten  minim  iloses, 
three  times  a  day.  Respiration  after  walking  32  to  44.  panting  and 
labored.  Acute  gaseous  indigestion.  Cannot  walk  half  a  block. 
Face  pallid  ;  apex  outside  nipple  ;  murmur  at  apex,  with  first  sound, 
carried  round  to  left ;  with  first  sound  carried  up  great  vessels. 
Urine  five  jniUs  per  day  :  no  allnnnin.  The  patient  was  i)ut  on  the 
modified  Nauheim  resistance  exercise  treatment,  with  baths.  .A.t 
first  the  exercises  were  mild,  with  lengthy  intermissions,  and  the 
baths  warm  and  salt:  temperature.  95°  ;  duration,  five  minutes.  At 
the  end  of  the  second  week  they  were  carbonated  and  given  immedi- 
ately before  bedtime.  Digitalis  stopped ;  sulphate  of  strychnine  one- 
sixtieth  of  a  grain  three  times  a  day  ;  arsenic  reduced  in  quantity. 
Examination  of  urine  (by  E.  E.  Smith,  Ph.D.)  :  Specific  gravity, 
1.020;  trace  of  albumin  ;  urea,  1.61  per  cent.,  8.34  grains  to  the  fluid 
ounce ;  a  few  uric  acid  crystals  ;  a  moderate  number  of  hyaline  and 
a  few  epithelial  casts  ;  .<;ugar  absent. 

February  25th — Pulse  75  to  84.  Respiration  20.  Patient  evi- 
dently better.  Ordered  Carlsbad  Salts  twice  a  week.  Two  meals 
only,  with  eight  ounces  of  meat  at  each  meal.  Patient  had  previ- 
ously accustomed  himself  to  two  meals  a  day.  Weight  now  350. 
Strychnine  one- thirtieth  of  a  grain  three  times  a  day.  Arsenic 
stopped. 

!\ larch  loth— Urine  re-examined  (E.  E.  Smith,  Ph.D.)  .  Sp. 
gr.,  1020.  Indican  ;  trace  of  albumin  ;  no  sugar  ;  urea,  1.55  per  cent., 
7.05  grs.  urea  to  the  ounce.  Xeutral.  Mucus  and  pus,  traces.  A 
few  hyaline  casts. 

]\Iarch  i6th — Girth.  60^  inches.  Patient  w^alks  a  little  farther 
each  day.  Temperature  of  bath,  93°  ;  seven  to  nine  minutes'  dura- 
tion. 

March  19th — Weight  348 V2  pounds.  After  baths  and  exercises 
a  fall  in  the  pulse  rate. 

March  23d — Pulse  has  been  ranging  as  follows :  Before  exer- 
cises, 81  to  88;  after,  jj  to  82 ;  before  the  bath,  80  to  90;  after,  80 
to  86.     Patient  is  drinking  Londonderry  Lithia  Water. 

April  2d — Weight,  343  pounds.  Water,  five  pints.  Sp.  gr., 
1820.      No  albumin  ;  phosphates. 

April  20th — Pulse  before  exercises,  •j'j  to  87 ;  after,  76  to  79 ; 
13  resistance  movements  daily,  total  duration  35  minutes.  More 
force  used.     Now  takes  Carlsbad  salts  daily  in  larger  doses,  caus- 


The  Fat  Heart  I2r 

ing  two  liquid  movements.      Milk  is  discontinued.     In  place  of  it 
liethesda  water,  with  a  little  lemon  juice,  to  aid  in  satisfying  thirst. 

Ai)ril  23d — Weight,  338  pounds.  Greatest  girth,  5o><  inches. 
Takes  no  breakfast.  In  place  of  it  a  glass  of  hot  water.  'J'akes 
Apenta  water  at  l)reakfast  time,  sometimes  followed  by  hot  water. 
After  two  months'  treatment  the  patient  reported  of  himself  as  fol- 
lows: ''Two  months'  treatment  shows  a  loss  of  nineteen  pounds  in 
weight,  and  a  reduction  of  ten  inches  in  measure  about  the  waist, 
with  marked  increase  of  strength  and  a  greater  freedom  in  breath- 
ing." 

May  2d — Resistance  exercises,  thirty  to  thirty-five  minutes.  Car- 
bonated baths  have  been  gradually  increased  to  their  full  strength, 
but  are  now  suspended. 

May  7th — Has  gained  three  pounds,  but  lost  nothing  in  girth. 
Ordered  baths  again  with  one-half  per  cent,  carbonic  acid. 

May  14th — Weight,  332^  pounds.  Lost  six  and  one-half 
pounds  in  seven  days.     Bath  now  every  other  night. 

May  26th — Gained  two  pounds  last  week.  Rubber  bandages 
now  removed.  Patient  walks  easily.  Ordered  to  take  only  one 
meal  per  day  for  one  day,  and  two  meals  on  the  alternate  da}'. 

June  4th — Weight,  327^/2  pounds. 

June  nth — Patient  going  to  the  country  is  directed  to  take  special 
resistance  exercises  daily.  To  take  hot  or  cold  water,  one  or  two 
goblets  with  orange  juice,  before  breakfast.  Then  to  take  a  hearty 
breakfast  and  a  light  supper.  To  eat  only  twelve  ounces  of  meat, 
fish  or  fowl  daily,  avoiding  starchy  and  sugary  food.  To  eat  spar- 
ingly of  small  fruits ;  to  avoid  fat  in  every  form,  including  butter, 
milk  and  gravies. 

In  January  of  1899  the  patient  reported  that  under  this  treatment 
his  weight  had  fallen  during  the  summer  to  317  pounds — a  loss  of 
forty  pounds.  During  all  this  time  he  had  attended  to  his  daily  pro- 
fessional routine  of  business,  while  in  the  city ;  and  made  long  trips 
out  of  town  in  consultation  cases,  where  he  was  obliged  of  necessity 
to  walk  long  distances  in  going  to  and  from  his  train.  Among  the 
noteworthy  features  of  this  case  is  that,  under  the  treatment,  the 
eczema  and  oedema  of  the  legs  disappeared,  and  that  he  graduallv 
gained  in  strength,  so  that  he  was  able  to  do  more  professional 
work,  during  the  treatment,  than  he  had  done  for  a  long  time 
previously. 

Case  XXXIV.  Obesity:  Fat  Heart;  Temporarx  Diabetes. — 
A  lady  of  about  sixty-five  came  to  me  on  October  4,  1898.  She 
weighed   181   pounds,  was  nervous  and  anjemic.      Skin  bathed  in 


122  The  Fat  Heart 

j)erspu-alion.  Color  dusky.  Tulsc  lOO  to  104.  Weak  impulse. 
Heart  enlarged.  Xo  organic  nuninurs.  Urine  examination  (by 
E.  E.  Smith.  I'li.O. )  :  Sp.  gr..  1027.  Faint  trace  of  sugar  by  sev- 
eral tests ;  no  albumin.  L'rea,  1.75  per  cent.,  7.95  grains  to  the  fluid 
ounce.  A  little  pus.  A  few  uric  acid  crystals.  Moilcrately  large 
quantity  of  hyaline  casts. 

October  2()th — Second  examination.  I'rinc.  60  oz.  Sp.  gr.. 
1018.  Alkaline  :  no  albumin.  Sugar  absent.  Urea,  2.28  per  cent., 
10.40  grains  to  the  fluid  ounce.  I'us  absent.  Moderate  number  of 
hyaline  casts. 

November  2d — C)rdered  anti-litli:emic  diet.    Resistance  exercises. 

November  14th — Resistance  exercises  and  massage.  One-half 
per  cent,  carbonic  acid  bath,  at  97°,  five  minutes.  Average  pulse  be- 
fore exercises  and  hath,  90;  after,  81. 

November  22d — Weight,   178 

November  28th — Weight.   177. 

December  21st — Weight,  171. 

The  treatment  was  now  stopped  by  an  attack  of  influenza,  the  pa- 
tient leaving  town  subsequently  for  a  short  trip  to  the  country. 
From  a  health  resort,  where  she  had  been  in  the  habit  of  going,  she 
reported  on  January  24th :    "The  doctors  here  think  me  much  im- 
proved."     Loss  of  weight,  about  five  pounds  a  month. 

Cose  XXXV.  Obesity;  Fat  Heart;  Dyspepsia.— A  gentle- 
man weighing  237  pounds,  height  5  feet  6  inches,  came  under  my 
care  in  December  of  1898.  Pulse  100,  no  intermissions.  Apex  beat 
feeble,  difficult  to  locate;  heart  enlarged.  Patient  a  smoker  and 
lith?emic.  Xo  organic  murmurs.  Pain  at  apex,  giddiness  of  head, 
acute  gaseous  dyspepsia,  and  d\'Spnoea.  Apex  four  and  three- 
fourths  inches  from  the  median  line,  and  three-fourths  of  an  inch 
below  the  intermammillary  line. 

December  28th. — Dyspepsia  and  regurgitation.  Under  subgallate 
of  bismuth,  Carlsbad  salts,  anti-lith?emic  diet,  and  abstention  from 
smoking,  these  disappeared. 

Januarv  27th. — Patient  took  the  modified  X^auheim  course  of 
resistance  exercises  and  baths.  Apex  now  about  four  inches  from 
the  median  line,  and  three-fourths  of  an  inch  below  the  intermam- 
millary line.  Takes  no  medicine.  Weight,  217  pounds  stripped. 
Had  lost  about  ten  pounds  in  a  month.  Pulse  of  better  quality; 
dvspnoea  gone,  and  the  patient  able  to  walk  fifty-five  blocks  in  a 
single  day. 

By  methods  such  as  are  given  here  it  is  possible  to  reduce  the 


The  Fat  Heart  123 

weiglit,  witliont  detriment  to  tlic  j:^eneral  health;  and  we  have  a 
right  to  assume  that  the  deposit  of  fat  in  the  heart  is,  measurably  at 
least,  diminished  with  the  loss  of  the  visible  adipose  tissue. 


Ciiapti:r  XI. 

FATTY  DEGEXERATiOX  Ul-   THE  HEART.' 

I'atty  degeneration  of  the  heart  was  first  correctly  differentiated 
from  tlie  fat  heart  of  obesity  by  Laennec-,  and  a  httle  later  by  An- 
dral'',  who  called  it  niinollisscDiciit  dii  cociir. 

The  source  of  this  degeneration  appears  to  have  been  discovered 
by  Hayem,'',  at  least  so  far  as  typhoid  fever  is  concerned.  In  1883 
Germain  See'  confirmed  this  view,  while  in  1891  Romberg,"  after  an 
elaborate  study  of  the  heart  substance  in  typhoid,  scarlatina  and 
diphtheria,  discovered  in  all  of  them  a  granular  and  fatty  degenera- 
tion of  the  heart-muscle,  together  with  a  small-celled  infiltration  of 
the  adjacent  connective  tissue.  In  1898  Bollinger"  adopted  this  view 
and  described  three  degrees  of  fatty  degeneration,  though  he  did 
not  intimate  that  they  might  be  three  stages  in  the  one  process.  In 
the  same  year  Dehio"*  confirmed  Hayem 's  views,  so  that  w^e  may  now 
regard  the  matter  of  fatty  degeneration  of  the  heart  as  fairly  under- 
stood, pathologicall}".  It  remains  for  us  to  attach,  if  possible,  clin- 
ical phenomena  to  the  successive  stages  of  its  development. 

It  is  very  important  to  put  this  matter  on  a  sound  clinical  basis, 
for  how  often  sudden  death,  from  heart  failure,  strikes  down  a  person 
who,  up  to  the  time  of  the  attack,  appeared  to  have  excellent  health. 
In  fact  his  physician,  after  examining  his  heart  and,  finding  no  signs 
of  valvular  disease,  may  have  been  content  with  the  diagnosis  of  a 
"weak  heart,"  and  yet  the  heart  substance  may  have  been  so  pro- 
foundly diseased  that  it  only  needed  a  sudden,  violent,  or  even  pro- 
longed, "strain"  to  cause  hyperdilatation  and  cardiac  paralysis. 

I  described  such  an  instance  at  a  meeting  of  the  N^ew  York 
Pathological  Society  some  years  ago  :'^ 

Case  XXXVI. — A  gentleman,  seventy-three  years  of  age,  who 
had  led  an  active  life  up  to  a  year  before  his  death,  was  suddenly 
taken  with  dyspnoea,  after  some  hill-climbing  in  California.  Up  to 
this  time  he  had  never  had  heart-symptoms.    He  recovered  promptly, 


'Originally  published  in  the  Med.  News,  Feb.  2,  1901. 
^Laennec,  Dis.  of  the  Heart  and  Lungs,  London,  1846,  p.  607. 
'  Andral,  Path,  intern..  Paris,  Vol.  I.,  p.  ,^24. 
*  Hayem,  Arch,  de  fihys.  norm,  et  path.,  1869,  Vol.  II.,  i,  p.  699. 
'Germain  See,  Maladies  du  cocur..  Paris.  1883,  p.  199. 
"Romberg,  Dcittseh.  Archiv.  f.  klin.  Med.,  Bd.  4S  u.  49,  1891-92. 
'Bollinger.  Path.  Anat..  New  York.  1898,  Vol.  I.,  p.  74. 
-Dchio,  Deutsch.  Archiv.  f.  klin.  Med..  1898.  LXII,,  s.  1-62. 
'  Satterthwaite,  Trans  of  N.   Y.  Path.  Soc.,  Oct.  22,  1879. 


Fatty  Degeneration  of  the  Heart  125 

however,  from  this  attack.  Later  he  took  a  25-iTiile  sleigh-ride  and 
had  anotlier  attack,  hut  was  restored  by  stimulants.  Five  weeks  be- 
fore his  death  he  lost  consciousness  in  a  street-car,  and  was  taken 
home  with  some  difficulty.  Stimulants,  however,  again  revived  him. 
An  examination  by  the  family  physician  showed  that  he  was  anaemic 
and  weak ;  the  pulse  could  not  be  felt,  and  the  apex  beat  was  barely 
apprecial)le.  He  did  not  rally.  At  the  post-mortem  examination, 
which  1  made,  there  was  a  marked  blanching  of  the  surface  of  the 
body.  The  lungs  were  oedematous  and  the  kidneys  pale  and  fatty. 
The  heart  was  not  enlarged,  but  it  was  pale  and  flabby. 

Microscopic  examination  of  the  cardiac  muscular  tissue  showed 
that  along  the  inner  wall  of  the  left  ventricle  the  striations  w-ere 
quite  gone,  though  they  were  fairly  well  marked  at  the  periphery  of 
this  ventricle.  There  was  no  valvular  disease.  In  this  patient  the 
initial  "strain"  to  the  degenerate  heart-muscle  seemed  to  be  directly 
traceable  to  the  hill-climbing  in  California.  Tliere  was  apparently 
no  other  lesion  to  cause  death. 

The  weak  heart  of  fatty  degeneration  is  common  enough  at  all 
periods  of  life.  In  infants  and  children  it  occurs  during  and  after 
the  eruptive  fevers  and  diphtheria,  acute  rheumatism,  pneumonia, 
influenza,  or.  in  fact,  any  acute  febrile  attack  of  toxaemia.  In  senil- 
ity, at  whatever  age  this  may  happen,  whether  early  or  late  in  life, 
it  is  a  phenomenon  to  be  expected.  In  fact,  w'henever  there  is  a  pro- 
longed fever,  toxaemia,  dyscrasia  or  mechanical  injury,  fatty  degen- 
eration of  the  heart  may  occur.  Very  often  the  so-called  "weak 
heart"  is  in  reality  the  heart  of  fatty  degeneration.  And  yet,  to 
judge  from  individual  experience,  as  derived  from  intercourse  with 
physicians,  and  from  our  current  literature,  the  matter  is  not  so 
understood  by  the  profession  at  large.  In  consequence  fatty  degen- 
eration may  be  recognized  too  late  for  treatment,  as  in  the  case 
just  cited. 

The  early,  or  preliminary  stage  is  the  one  in  which  the  prognosis 
is  the  most  favorable  for  complete  recovery ;  in  the  second,  or  inter- 
mediate stage  we  should  be  able  to  hold  the  disease  in  check ;  in  the 
third,  or  tina/,  stage  palliative  treatment  alone  is  possible. 

If.  however,  we  are  to  grasp  the  matter  intelligently,  we  must 
first  of  all  look  to  the  minute  structure  of  the  heart-muscle.  Though 
involuntary,  it  is  made  up,  as  we  all  kno\\-,  of  muscle-cells  marked 
by  longitudinal  and  cross  striations.  The  body  of  each  cell  is  cylin- 
drical and  contains  one  or  two  nuclei.  The  nucleus  is  vesicular  and 
oval,  and  is  placed  near  the  centre  of  the  cell-bodv.     The  cells  are 


126  Fatty  Degeneration  of  the  Heart 

not  onlv  ioiiiecl  at  their  ends  with  ciuilii;iunis  cells;  hut,  throug-h 
hranchos.  with  other  cells,  niakini^'  up  a  reticular  uetwork.  The  ap- 
]KXsition  of  the  cells  is  effected  hv  a  cement  suhstance,  that  is  not  seen 
under  ordinary  conditions  ;  and  the  network  holds  in  its  meshes  ves- 
sels, nerves  and  fat. 

In  inflammation  of  this  nniscle  the  cells  become  opaque,  owing- 
to  their  intiltratit)n  with  i^ranular  matter,  or  at  least  with  something 
presenting  that  appearance  (cloudy  swellino),  and  the  particles  have 
been  termed  alhumiuoid,  because  they  disappear  to  some  extent  un- 
der the  action  of  weak  acids  or  alkalies.  One  theory  that  has  been 
proposed  is  that  this  albuDi'uioid  material  is  formed  from  the  cyto- 
plasm of  the  cells.  Another  theory  supposes  that  the  granules  rep- 
resent the  toxic  elements  of  the  disease :  another  that  they  are  effete 
matters  being  eliminated;  an(nher  that  they  are  micro-organisms; 
another  that  they  are  fatty  particles  in  a  stage  of  minute  deposition. 
It  is  certain,  however,  that  some  of  them  are  pigmentary,  and  also 
that  in  poisoning  by  phosphorus,  arsenic  and  in  typhoid  fever,  many 
are  either  fattv  or  of  some  closely  allied  substance.  So  much  for  the 
first  stage. 

In  the  second,  or  intermediate  stage,  the  muscle  cells  are  clearly 
seen  to  be  studded  with  oil  globules,  which  appear  to  occupy  the 
same  position  as  the  "albuminoid"  and  fatty  particles  of  the  first 
stage. 

In  the  final,  or  third  stage,  the  fatty  globules  reach  a  higher 
degree  of  development,  while  occasionally  the  muscle-cells  are  pulled 
apart  {sedimentation),  or  broken  into  fragments  (fra,^inenfati'oii), 
as  the  result  of  hyperdilatation  of  the  heart  chambers.  In  this  stage 
there  is  an  engorgement  of  the  blood-vessels  of  the  internal  viscera, 
limiting  their  functional  activity  and  causing  hyper?emia.  oedema, 
thrombosis  or  embolism.  Renaut^"  has  gone  so  far  as  to  classify 
segmentation  as  a  variety  of  chronic  myocarditis,  which  he  has  called 
myocardife  segmentaire  chronique.  At  first,  this  view  met  with 
opposition  from  Zieglcr  and  Recklinghausen,  who  regarded  seg- 
mentation as  an  agonal  manifestation.  Hektoen.''^  of  Chicago,  how- 
ever, after  examining  eighty  hearts  to  test  the  matter,  came  to  the 
following  conclusions:  Se^mevtation  and  fra^me^itat'ww  do  occur 
in  heart-muscle  durluf:^  life  in  consequence  of  irregular  contractions 
or  injuries,  usually  associated  with  disease  of  the  heart-walls.  If 
the  segmentation  or  fragmentation  is  limited  in  area,  it  is  not  immedi- 
atelv  fatal.  Consequently  we  are  forced  to  believe  that  both  seg- 
mentation and  fragmentation  are  real  events  in  heart-strain,  con- 


'"Renant.  Cue.   Med.   dc   Paris.    lOQO.   o.    too. 
"Hektoen,  Trans  of  Path.  Snr.  nf  Phila..  tPqS.  p.  267. 


Fatty  Degeneration  of  the  Heart  127 

tribnting-,  of  ccnirse,  to  the  fatal  issue,  though  they  hardly  seem  to 
lie  worthy  of  a  separate  classification. 

Reverting  for  a  moment  to  the  subject  of  the  so-called  albu- 
minoid change,  a  theory  has  been  advanced  that  in  exhausting  dis- 
eases associated  with  prolonged  fever  in  which  the  cardiac  muscle 
is  actually  starving  from  lack  of  nourishment  it  makes  a  demand, 
in  its  hunger,  on  the  store  it  has  already  accumulated,  viz.,  the  meta- 
])lasm  of  the  muscle-cell ;  but  if  this  is  exhausted  and  more  is  needed, 
it  is  compelled  to  consume  its  own  substance.  Now  the  reserve 
stock  in  the  meshes  of  the  muscle-cells  is  made  up  of  carbohydrates, 
and  there  is  no  harm  done  to  the  cell  by  their  consumption.  When, 
however,  the  living  tissue  of  the  cell  has  to  be  sacrificed,  there  is  a 
loss  of  the  proteids  or  albuminoid  substances  of  the  cell,  and  the 
damage  done  is  directly  proportionate  to  the  amount  consumed ; 
and  yet  the  combustion  is  incomplete,  a  granular  debris  being  left 
behind  in  the  cells.  But  consumption  may  proceed  a  step  further, 
so  that  both  the  fatty  matters  and  the  fluids  of  the  protoplasm  are 
burned,  though  the  combustion  is  still  incomplete,  and  a  further 
residue  of  oil  is  left  behind  in  the  cells.  Still,  even  now,  a  restoration 
of  the  cells  is  possible,  provided  only  the  nucleus  has  been  left  unim- 
paired.    Death  of  the  nucleus,  however,  means  death  to  the  cell. 

Quite  a  different  view  has  been  given  by  Huchard.^-  It  is  that 
the  first  stage  of  fatty  degeneration  is  due  to  the  irritation  of  a 
micro-organism  or  toxin,  which,  if  sufficiently  virulent,  causes  in- 
flammation and  perhaps,  ultimately,  necrobiosis  of  the  cell.  This 
last  theory  is  plausible,  but  it  does  not  apply  to  the  fatty  degenera- 
tion seen  in  retrograde  changes,  such  as  occur  in  the  parturient  or 
athletic  heart  and  in  adherent  pericardium,  where  the  fatty  de- 
generation of  certain  portions  of  the  cardiac  walls  appears  to  be  due 
directly  to  lack  of  use ;  for  when  certain  fibres  are  no  longer  needed 
thev  are  pretty  sure  to  degenerate  and  eventually  disappear. 

So  much  for  the  theories  of  the  production  of  fatty  degeneration. 
Accepting  the  dicta  of  Hayem.  Romberg  and  Huchard,  the  acute 
stage  is  essentially  a  fatty  one ;  that  is,  so  far  as  the  acute  softening 
in  typhoid,  scarlatina  and  diphtheria  is  concerned. 

Fat  deposition  or  accumulation,  in  the  heart,  the  fat  heart  of 
obesity,  is  quite  another  condition  etiologically  and  pathologically. 
Fat  accumulates  in  the  connective  or  interstitial  tissues  lying  be- 
tween the  muscle-bundles.  It  is  the  result  of  overfeeding  either 
with  fattv  food,  or  anv  food  material  that  is  in  excess  of  bodilv  re- 


"  Huchard,  Ph.iJa.  Med.   Times,  March  24,  igoo. 


128  Fatty  Degeneration  of  the  Heart 

qiiircmonts  :  but  clinically  the  two  processes  are  to  some  extent  al- 
lied, for  the  muscle-tissue  may  sutier  atrophy  in  the  fat  heart  from 
pressure  of  tlie  fat  tissues  ;  or  the  fibres  may  be  so  separated  or  over- 
stretched that  their  intes;rity  is  impairetl,  and  thev  will  degenerate 
in  consequence.  .  i-'at  ileposition  antl  fatty  degeneration  may,  there- 
fore, coexist  in  the  same  heart ;  and  yet  while  fat  deposition  is  apt  to 
cause  fatty  degeneration,  fatty  degeneration  never  causes  fat  depo- 
sition. 

To  the  naked  e_\e  there  is  little  difhculty  in  recognizing  fatty 
degeneration  in  the  heart-muscle  b\-  its  pale  yellow  color,  well  shown 
beneath  the  lining  membrane  of  the  left  ventricle  or  papillary  mus- 
cles, in  nearly  every  heart  in  which  there  is  chronic  valvular  dis- 
ease; but  the  eye  will  often  fail  to  recognize  it  in  the  softened  heart 
of  typhoid  fever  or  diphtheria,  for  the  tissue  will  not  be  yellow,  but 
of  a  muddy,  brown  color ;  or,  if  there  is  a  fibroid  element,  the  color 
may  be  violet-brown  or  violet.  It  occurs  in  localized  areas  present- 
ing a  mottled  appearance  ;  or  is  difi;use  and  the  special  area  of  soft- 
ening "mushy."  so  that  in  handling  the  heart  the  fingers  sink  into  it. 
The  left  ventricle  is  chiefiy  afi'ected,  at  first. 

Fatt\-  degeneration  taken  in  the  broad  sense  that  I  have  indicated 
nmst  be  ((uite  frequent.  Roemer,  of  Tubingen,  between  1870  and 
1890,  saw  at  his  clinic  291  cases  of  valve  lesions,  in  which  230 
show'ed  symptoms  of  disturbed  compensation,  while  at  the  same  time 
there  were  2t,^  cases  that  he  called  myopathic  heart-failure,  with- 
out an\-  lesions  of  the  valves.  Now,  as  most  of  these  234  cases 
were  probably  instances  of  fatty  degeneration,  heart-failure  without 
valve  lesions  was  about  as  common  as  heart-failure  with  valve 
lesions.'"  Chronic  fatt_\-  degeneration  of  the  heart  is  usually  asso- 
ciated with  cardiac  hypertrophy,  atrophy,  fibroid  disease,  fatty  depo- 
sition, chronic  endo-  and  pericarditis,  and  some  other  cardiac  or 
arterial  disease.  For  example,  Ouain  found  hardening  or  calcifi- 
cation of  the  coronary  arteries  in  13  out  of  t,t,  cases  of  fatty  degen- 
eration ;  ]\larkham  in  one  out  of  12  (Whittaker)  ;  so  that  arterio- 
sclerosis may  be  regarded  as  one  of  the  causes  of  fatty  degeneration. 
It  is  an  unfortunate  idea  prevailing  in  some  quarters  that  coronary 
disease  has  a  preponderating  etiological  connection  with  fatty  de- 
generation. This  is  not  true,  though  it  is  not  at  all  uncommon  for 
me  to  have  a  case  of  fatt\-  degeneration  turned  over  to  me  with  the 
label  "coronarv  disease."     With  some  physicians,  I  might  also  add, 


"Whittaker.  Tivcnficth  Crnlitry  Practice.  Vol.   TV.  p.  340. 


Fatty  Degeneration  of  the  Heart  129 

the  term  "myocarditis"  means  fatty  degeneration,  though  tliey  are 
obviously  two  (Hstinct  processes. 

We  usually  meet  with  the  chronic  variety  of  fatty  degeneration 
in  middle  life,  though  it  may  of  course  occur  at  earlier  periods.  In 
88  cases  published  by  Hayden,^*  fatty  degeneration  was  found  most 
commonly  between  sixty  and  seventy,  less  often  between  forty  and 
fifty  years  of  age. 

It  is  extremely  important  for  us  to  recognize  the  early  or  prcnif^ni- 
tory  stage,  as  bearing  both  on  prophylaxis  and  treatment.  Unfor- 
tunately this  is  not  always  possible.  In  mild  cases  the  physical  signs^ 
may  be  absent,  for  there  may  not  be  any  appreciable  dilatation,  andl 
the  physical  signs  depend  on  this  circumstance.  Hence  the  import- 
ance of  outlining  the  heart  by  percussion ;  for  variations  in  outline 
from  the  standard  will,  in  some  degree,  indicate  whether  the  right  or 
left  ventricle  is  dilated  ;  and  the  position  of  the  apex  will  aid  greatly 
in  determining  whether  the  heart  is  enlarged.  Besides,  the  impulse  at 
the  apex  will  be  more  or  less  feeble,  and  the  pulse  will  be  intermittent 
and  rapid.  The  sounds  of  the  heart  will  also  be  weak.  There  may 
not  be  any  murmurs,  or,  in  the  absence  of  valvular  disease,  there 
may  be  systolic  murmurs  due  to  muscular  insufficiency.  If  there 
is  hypertrophy  of  the  right  ventricle,  following  dilatation  of  the 
left  ventricle,  there  will  be  an  accentuation  of  the  second  pulmonary 
sound. 

There  may  also  be  prrecordial  pain  or  distress  and  spells  of  dizzi- 
ness or  fainting.  This  stage  may  last  a  few  days,  weeks,  or  months  ; 
or  longer,  after  diphtheria  and  influenza.  A  few  cases  taken  from 
my  pathological  records  while  pathologist  to  the  St.  Luke's  and 
Presbyterian  Hospitals  illustrate  the  subject  of  fatty  degeneration: 

Ca.se  XXXVII.  Acute  Pericarditis;  Empyema;  Fatty  Degenera- 
tion of  the  Heart. — A  drinking  man,  thirty-eight  years  of  age,  en- 
tered the  hospital  with  an  empyema,  the  abscess  discharging  in  the 
mammary  region.  Pulse  100;  respiration  31  to  36;  temperature 
102°  F. ;  dyspnoea,  prsecordial  pain,  cough,  mucous  expectoration 
and  night-sweats.  After  battling  with  the  attack  for  three  months 
the  patient  died  of  cardiac  failure.  At  the  post-mortem  examina- 
tion, the  opposing  surfaces  of  the  pericardium  were  found  to  be 
acutely  inflamed  and  "hairy."  The  pericardial  sac  contained  three 
ounces  of  clear  serum.  The  heart  was  dilated  and  in  a  condition  of 
acute  softening.  Fifteen  ounces  of  purulent  fluid  were  taken  from 
the  pleural  cavities.     This  was  an  example  of  fatty  degeneration 


Hayden.    Dis.  of  the  Heart.  Dublin,  1875,  p.  66. 


130  Fatty  Degeneration  of  the  Heart 

of  the  heart  in  the  first  stage,  thie  to  a  conihination  of  two  causes, 
acute  pericarditis  and  enipyenia.  The  cardiac  syniptnms  were  not 
clear,  beinq^  obscured  by  those  of  the  empyema. 

Case  XXXJ'IIJ.  y'cllow  fczrr;  Fatty  Degeneration  of  the  Heart. 
— This  ease  also"  ilhistrates  fatty  degeneration  of  the  first  stage,  in  a 
marked  manner.  M.  C.  thirt\-t\vo  years  of  age,  widow,  stewardess, 
was  admitted  to  the  hospital  July  25.  1870.  with  yellow  fever.  Her 
illness  dated  back  only  five  days,  when  she  was  taken  with  frontal 
headache  and  general  "soreness""  of  back  and  legs.  The  initial 
chill  was  followed  l:)y  nausea,  diarrhoea  and  fever.  Pulse  108.  and 
•weak:  temperature  105'^  F.  On  the  ninth  (la\-  slie  vomited  dark 
matter,  became  delirious  and  had  albumin  (50  per  cent.  b\-  volume)  ; 
scanty  water.  .\.t  the  post-mortem  examination  the  heart  was  found 
to  weigh,  ten  ounces  and  was  soft,  flabby  and  fatty.  The  valves, 
however,  were  free  and  normal.  This  fatty  condition  of  the  heart 
liad  previously  been  noted  by  Dr.  H.  D.  Schmidt,  of  Xew  Orleans, 
as  a  characteristic  of  yellow  fever,  with  at  the  same  time  fatty  de- 
generation of  other  internal  organs,  including  the  brain.  This  case 
r  regard  as  another  instance  of  fatty  degeneration  in  the  first  stage. 
I  made  the  microscopic  examination  of  the  heart. 

In  the  seco)id  stage  the  signs  of  a  dilated  heart  are  more  pro- 
nounced. The  left  ventricle  may  reach  to  the  left  nipple  or  extend 
Ijeyond  it;  the  right  ventricle  an  inch  or  more  bexond  the  right  bor- 
'<^ler  of  the  sternum.  The  apex  may  be  in  the  fifth,  sixth  or  seventh 
space.  The  pulse  will  usuallv  be  soft,  intermittent  and  infrequent. 
There  may  be.  and  often  is.  a  lack  of  harmony  lietwecn  the  heart 
and  pulse-beats.  These  manifestations  are  apt  to  be  seen  (though 
not  always),  in  i)ersons  who  liave  ]iassed  middle  life,  and  are  in- 
clined to  l)e  stout,  Init  are  aucemic  in  ai)i)earance.  I'he  ape.x 
beat  will  be  difficult  or  impossible  to  locate  by  pal])ation.  There 
will  be  dyspnrea  and  some  precardial  oppression,  with  occasional 
attacks  of  diz/.iness.  Abdominal  sxmptoms  will  always  be  in  evi- 
dence ;  occasionally  gastric  crises  alternating  with  anginoid  attacks. 
Cyanosis  will  occur  at  times.  Such  ]:)atients  will  usually  be  irri- 
table or  whimsical,  or  nervous  about  trifles,  and  always  concerned 
about  their  health.  There  will  be  a  disinclination  to  undertake  any- 
thing new,  even  to  walk,  and  the  gait  will  be  uncertain.  Occasion- 
ally there  will  be  hemorrhages.  usuall\  in  the  form  of  epistaxes.  Lo- 
cal oedema  of  face,  hands  and  feet  will  occur  at  times.  The  urine 
will  contain  a  little  albumin,  and  often  a  little  sugar.  This  stage 
ma\'  last  frrmi  two  or  three,  to  ten  or  fifteen  or  even  twentv  years. 


Fatty  Degeneration  of  the  Heart  131 

depending-  largely  on  the  degree  of  the  degeneration  and  the  earc 
the  patient  takes  of  himself. 

The  third  stage  is  ushered  in  by  symptoms  that  indicate  secondary 
implication  of  other  organs.  There  may  now  be  pseudo-apoplectic 
attacks,  due  to  cerebral  embolism  or  thrombosis  referable  to  imper- 
fect heart-action.  Attacks  of  heart-failure  are  nu^re  frefjuent  and 
more  alarming.  Albuminuria  is  more  in  evidence  and  less  ame- 
nable to  treatment.  In  fact,  sym])toms  referable  to  chronic  nephritis 
are  the  rule.  Gastric  disturbances  become  so  pronounced  that  the 
patient  is  afraid  to  eat  for  fear  of  the  distress  it  occasions.  Local 
cedema  passes  over  into  general.  Thrombosis  may  be  a  noteworthy 
feature.  In  one  of  my  cases  thrombi  distending  the  right  external 
jugular  vein  were  distinctly  felt.  A  low  form  of  meningitis  from 
efifusion  at  the  base  may  be  one  of  the  final  events.  The  mind  will 
be  disturbed  and  there  may  be,  at  times,  Cheyne-Stokes  breathing, 
though  this  is  not  necessarily  a  sign  of  immediate  dissolution.  Un- 
til stasis  occurs  in  internal  organs,  however,  we  should  not  despair ; 
but  where  this  takes  place,  and  this  condition  characterizes  the  third 
or  final  stage,  the  end  cannot  be  far  off.  With  great  care  life  may 
be  prolonged  a  few  months.  Death  may  occasionally  occur,  how- 
ever, not  from  any  of  the  above  causes,  but  from  rupt^irc  of  the 
heart.     Ouain  has  seen  it  in  28  out  of  83  cases. 

This  stage  is  illustrated  by  the  following  three  cases : 

Case  XXXIX.  Syphilis;  Chronic  Nephritis;  Fatty  Degeneration 
of  the  Heart. — A  man,  forty-six  years  of  age,  entered  the  hospital 
with  the  signs  of  general  syphilis.  Fie  had  cough,  jaundice,  dyspnoea 
and  swollen  feet.  A  soft  systolic  murmur  was  heard  at  the  apex.  The 
patient  died  fifteen  days  after  admission,  of  chronic  nephritis.  At 
the  post-mortem  examination  the  pericardial  sac  was  found  to  con- 
tain ten  ounces  of  clear  serum,  and  there  were  several  milk  patches 
on  the  heart.  It  weighed  eighteen  ounces.  There  were  no  valve 
lesions.  The  liver  was  large  and  fatty. '  The  kidneys  were  the  seats 
of  chronic  nephritis.  At  the  autopsy,  the  murmur  was  held  to  be 
muscular,  and  due  to  fatty  degeneration  of  the  heart.  Syphilis  was 
pretty  certainly  the  remote  cause  of  the  fatty  degeneration. 

Case  XL.  Arteriosclerosis;  Cerebral  HccniorrJiagc :  Fatty  De- 
generation of  the  Heart. — The  following  is  another  of  my  cases : 
A  woman,  thirty-eight  years  of  age.  who  said  she  had  suffered  from 
"malaria,"  was  admitted  to  the  hospital  with  oedema  of  the  lower 
extremities.  She  complained  of  attacks  of  palpitation,  with  prse- 
mrdial  pain,  tonic  spasms  and  dvspncea.     The  pulse  was  intermit- 


132  Fatty  Degeneration  of  the  Heart 

tent,  and  the  aortic  second  sound  acceniualed.  The  patient  died  of 
cerebral  lictniorrhage.  The  autopsy  disclosed  general  arterioscle- 
rosis with  chronic  diffuse  nepliritis.  The  heart  was  dilated  and  soft, 
but  the  valves  were  free  and  sufficient.  The  cause  of  the  fatty  de- 
generation in  this  case  with  aricrinsclerosis,  and  the  death  by  cere- 
bral haMUorrhage  illustrates  one  of  the  several  wa}s  in  which  the 
end  comes  at  last. 

Case  XLl.  .-idiicroit  Pcriainiiuni :  Fatty  Degeneration  of 
Heart. — A  woman.  sixt}-three  years  of  age,  with  a  history  of  artic- 
ular rheumatism,  was  admitted  to  the  hospital  suffering  from  cough, 
hemoptysis,  dyspnoea  and  chronic  nephritis.  She  also  had  a  systolic 
nnirmur  over  the  apex,  and  over  the  aortic  and  pulmonary  areas, 
with  accentuation  of  the  second  pulmonary  sound.  She  died  of 
cardiac  paralysis  and  chronic  nephritis.  At  the  autoi)sy  the  heart 
was  ft)und  to  weigh  twelve  ounces.  The  valves  were  free  and  sufift- 
cient ;  but  the  cardiac  walls  were  soft  and  Habb)-,  and  the  cavities 
of  the  heart  dilated.  1lie  heart  and  pericardium  were  united  by  an 
old  adhesive  pericarditis.  The  liver  was  large  and  fatty.  In  this 
instance  we  see  the  fatty  degeneration  of  the  heart  always  found  in 
adherent  pericardium,  though  the  toxins  of  rheumatism  may  be 
assumed  to  have  been  early  factors  in  causing  degeneration,  inde- 
pendently of  the  pericarditis,  which  operated,  in  a  purely  mechanical 
manner,  to  produce  the  fatty  change.  This  case  is  another  instance 
of  fatty  degeneration  in  the  third  stage. 

If,  then,  we  realize  that  this  affection  of  the  cardiac  walls  is  in- 
cidental to  infective  diseases,  continued  fevers,  septic  or  suppurative 
processes,  toxaemias,  dyscrasias,  hypertrophies  and  atrophies,  we 
should  be  on  our  guard  to  protect  the  patient  against  the  inherent 
damage  to  the  heart  resulting  from  these  several  conditions.  We 
should  thus  hope  either  to  prevent  a  break-down  of  the  cardiac  walls, 
or  certainly  to  postpone  it.  In  infants  or  young  children  con- 
valescing from  eruptive  or  continued  fevers  we  should  watch  care- 
fully their  "weak  hearts."  With  them  rest  in  bed  and  minute  doses 
of  iron  and  strychnine,  perhaps  in  conjimction  with  some  malt  prep- 
aration and  cod-liver  oil  or  quinine,  will  usually  be  sufficient,  in 
uncomplicated  cases,  provided  the  diet  is  carefully  regulated,  and 
hurried  movements,  or  any  form  of  muscular  strain  or  nervous  ex- 
citement are  avoided. 

In  young  people,  such  as  are  anremic  or  tuberculous,  gymnastic 
exercises  are  appropriate  for  the  intermediate  stage,  provided  they 
are  given  under  suitable  medical  direction  and  are  not  carried  to 


Fatty  Degeneration  of  the  Heart  133 

the  extreme  that  is  common  at  the  present  clay,  in  gymnasiums  and 
outdoor  games.  There  are  plenty  of  schools  for  physical  instruc- 
tion, under  medical  supervision,  where  those  convalescing  from  ill- 
ness with  weak  heart-action  can  be  greatly  improved.  On  the  other 
hand,  I  cannot  too  strongly  condemn  the  class  exercises  of  the  day, 
if  the  patient  has  heart-weakness  or  in  fact  any  form  of  heart-dis- 
ease. Class  work  calls  for  uniform  movements,  usually  rapid,  which 
give  few  intermissions  for  breathing;  so  that  it  is  only  suited  for 
those  whose  hearts  are  sound. 

In  fact,  every  case  of  weak  heart  should  be  treated  by  itself, 
whether  in  the  young  or  old,  and  the  exercises  should  never  be  car- 
ried to  the  point  of  increasing  the  rapidity  of  the  heart's  action  be» 
yond  its  normal  range,  which  of  course  differs  with  each  individual ; 
for  although  we  have  adopted  an  artificial  standard  for  the  rapid- 
ity of  the  pulse,  one  man's  normal  pulse  may  be  60  or  less,  and  an- 
other's 80  perhaps,  or  more.  Systematic  exercise  of  a  specially  '^ve- 
scribed  variety  should  be  insisted  on,  because  habits  of  indolence  tend 
to  a  fatty  heart,  and  will  increase  the  difficulty.  In  fact,  oily  matter 
of  any  kind  should  be  consumed  by  muscle  work.  At  the  same  time, 
patients  should  be  put  on  a  specially  restricted  diet.  It  prevents 
gaseous  distention  of  the  stomach  and  intestines,  which  provokes 
cardiac  irregularity. 

When  young  or  old  people  have  not  the  strength  for  ordinary 
gymnastics  they  should  have  resistance  exercises,  with  or  without 
massage.  These  exercises-  are  more  thorough  than  massage,  and 
tend  to  rid  the  muscle-cells  of  their  granular  contents,  whether  they 
are  toxic  or  otherwise.  But  with  delicate  patients  massage 
and  exercises  may  be  too  severe  a  tax  on  the  strength,  producing 
too  profound  a  reaction.  The  treatment  should  always  have  the 
effect  of  toning  up  rather  than  relaxing  the  individual.  Carbonated 
baths,  of  course,  are  to  be  used  in  conjunction  with  resistance  exer- 
cises, in  the  intermediate  stage  of  the  disease;  but  baths  and  exer- 
cises are  of  little  or  no  use  in  the  third  stage.  And  yet  while  they 
may  not  do  any  good,  they  may  not  do  any  harm.  Massage,  how- 
ever, is  often  very  grateful. 

Roemer,  quoted  by  Whittaker,^^'  reports  that  in  234  cases  of 
heart- weakness  without  valve  lesions,  where  81  of  thern  were  treated 
by  the  mechanico-dietetic  improved  Nauheim  plan,  46  recovered 
and  17  were  improved.  But  neither  exercises  nor  baths  should  be 
instituted,  until  a  careful  physical  examination  of  the  patient  has 


"Whittaker,    Loc  cit. 


134  Fatty  Degeneration  of  the  Heart 

boon  made.  If.  for  oxaniplc.  lie  is  snfieriny  from  a  violent  attack 
of  palpitation,  rest  in  bed  in  a  tjuiet  room,  and  a  restricted  diet, 
sliouUl  be  ordered.  Milk  is  excellent  if  it  agrees  with  the  patient. 
In  ordinary  cases  of  fatty  dei^eneration  the  ])atient.  if  anaemic,  should 
he  ])ut  on  iron:  if  tul)erculous.  on  malt  preparations  and  creosote 
or  cod-liver  oil:  if  arteriosclerosis,  on  the  iodides:  if  rheumatic,  on 
antilithiemic  diet  aild  remedies,  in  conjunction  with  the  hot-air  treat- 
ment. 

In  the  third  stage,  when  all  hope  of  cure  by  any  of  the  above 
measures  is  at  an  end.  and  it  is  merely  a  question  (~>f  prolon_t;inf;^  life 
and  alleviating;-  sutterinp;,  dii^italis  is  ap])roi)riate,  if  there  is  an  efTu- 
t^ion  referable  to  the  failing;  action  of  the  heart,  through  inaction  of 
the  kidneys.  Merck's  digitaline  (m  i/ioo  grain  doses  every  few 
hours).  1  have  ft)und  excellent:  but  digitalis  should  not  be 
continued  for  more  than  a  week  or  so  at  a  time,  and 
strichnine  should  follow  it  to  maintain  its  effects.  Other 
remedies  that  are  useful  in  this  stage  are  nitroglycerine,  cafifeine, 
strophanthine  and  sparteine.  Attacks  of  difficult  breathing,  if  not 
severe,  are  relieved  by  oxygen  gas.  while  sudden  attacks  of  true  or 
false  angina  are  best  treated  by  the  nitrites.  And  yet  in  the  third 
stage  it  must  be  remembered  that  the  degenerate  heart  has  a  remark- 
able capacity  for  recovery,  even  without  the  so-called  heart  stimu- 
lants. If  given,  their  action  should  be  constantly  watched  and  they 
should  only  be  used  for  the  briefest  possible  period.  These  remarks 
are  especially  applicable  to  digitalis,  strophanthus,  scoparius  and 
nux  vomica. 

The  prognosis  of  fatty  degeneration  varies  with  the  stage,  the 
individual,  his  environment,  and  the  influence  of  the  disease  which 
has  produced  it ;  for  fatty  degeneration  is  not  strictly  a  disease  siii 
generis,  but  a  degenerative  process  superinduced  by  a  number  of 
diseases.  For  example,  the  fatty  changes  attendant  on  infective  dis- 
eases of  toxixmias  should  disappear  entirely,  provided  the  heart  has 
had  rest  during  the  stage  of  convalescence.  On  the  other  hand,  if 
during  convalescence  the  patient  has  been  called  upon  to  do  an  im- 
proper amount  of  physical  work,  dilatation  may  ensue  and  fatty  de- 
generation be  produced.  In  infants  and  young  children  fatty  changes 
in  the  heart  incidental  to  infective  diseases,  or  as  sequels  of  them, 
are  quite  common.  On  the  other  hand,  a  moderate  amount  of  fatty 
degeneration  is  not  inconsistent  with  an  average  life ;  in  fact,  there 
is  a  certain  amount  of  fatty  degeneration  in  most  adult  hearts 
otherwise  sound,  reflecting  probably  the  methods  of  life  in   what 


Fatly  Degeneration  of  the  Heart  135 

we  call  civilized  cfjmnmiiitics,  where  the  intellectual  rather  than  the 
physical  parts  of  our  system  are  most  in  use.  'Ihis  is  well  shown 
in  the  hearts  of  athletes;  for  when  hypertrophy  has  been  caused  by 
severe  training,  there  seems  to  be  always  a  certain  amount  of  fatty 
degeneration  coincident  with  the  gradual  return  of  the  heart  towards 
its  normal  size,  which  retrograde  ])rocess  takes  place  when  ath- 
letics are  given  u])  for  the  ordinary  routine  of  a  business  or  pro- 
fessional life.  In  such  cases,  however,  when  the  enlarged  heart 
fails  to  contract  to  the  normal  size,  we  may  infer  that  the  delay  is 
owing  to  some  other  organic  heart  affection,  such  as  valvular  dis- 
ease or  mechanical  injury  or  an  old  strain. 

In  the  middle  period  of  life,  when  degenerative  changes  are 
the  rule,  a  weak  heart  may  be  toned  up  and  restored  to  a  fair  degree 
of  soundness  by  appropriate  treatment ;  though  it  is  one  thing  to 
make  an  organ  sound  physiologically  and  quite  another  to  have  it 
sound  pathologically.  And  yet  it  is  always  a  triumph  of  medical  art 
to  restore  the  functions  of  any  organ. 

In  the  tinal  stage  when  anasarca  supervenes  and  the  kidneys, 
from  hypersemia  or  structural  changes,  secrete  a  lessened  amount 
of  urine,  containing  albumin  and  granular  casts  ;  and  there  is  transu- 
dation of  fluids  into  the  bronchi,  lungs,  or  chlylopoetic  tract,  inter- 
fering with  the  functions  of  these  organs,  the  prognosis  cannot  be 
favorable.  The  fatal  issue  is  certainly  near  at  hand  and,  though 
the  heart  may  be  sustained  and  the  kidneys  forced  to  do  better  work, 
it  is  a  struggle  in  which  Nature  will  eventually  triumph  most  likely 
by  thrombosis  or  embolism ;  perhaps  by  apoplexy,  meningitis  or 
ura?mia. 


;  Chapter  XII. 

SYPHILIS  OF  THE  HEART. 

Before  Ricord's^  time  cardiac  syphilis  had  been  recognized,  but 
he  was  the  first  to  describe  it  clearly.  Shortly  afterwards  Virchow- 
confirmed  Ricord's  statements.  A  few  years  later  Lancereaux' 
classified  it  under  four  types.  But  grave  doubts  were  still  enter- 
tained of  its  existence,  and  they  are  only  now  being  successfully 
overcome,  though  a  great  deal  has  been  written  on  the  subject  since 
Ricord's  time.''  The  instances,  however,  that  are  conclusive,  from 
a  pathological  point  of  view,  have  been  comparatively  rare.  The 
naked-eye  appearances  in  syphilis  show  nothing  that  is  positively 
distinctive,  if  we  except  gummy  tumors,  and  they  arc  seldom  de- 
tected. Indeed,  so  keen  an  observer  as  Fagge^'  had  failed  to  rec- 
ognize more  than  four  cases  up  to  1886,  notwithstanding  his  long 
pathological  service  at  Guy's  Hospital.  Only  one  of  them  was 
classed  as  a  gummy  tumor,  three  being  fibroid  infiltrations 
of  the  heart  walls.  In  ni}-  own  pathological  records  I  have  only 
three  cases  put  down  to  cardiac  syphilis,  and  am  still  in  some 
doubt  as  to  their  true  character.  And  yet  I  believe  many  syphilitic 
manifestations  are  overlooked  at  post-mortem  examinations,  simply 
because  the  naked  eye  evidences  are  inconclusive.  However,  the 
researches  oi  Mracek^'  and  Kundrat,  of  \"ienna,  should  set  at  rest 
forever  the  question  of  the  existence  of  this  cardiac  lesion,  for  in 
1893  ^^^  published  a  series  of  102  cases  in  which  the  evidences  were 
established  b}-  autopsies.  His  table  indicates  the  different  ways  in 
which  he  found  that  s}philis  may  affect  the  heart.  As  taken  from 
the  literature,  including  ten  cases  of  his  own,  it  is  as  follows: 

Myocarditis,  gummatous    l 10 

fibrous    9 

"  gummatous  and  fibrous 8 

Endocarditis    2 

Pericarditis    i 

Diseases  of  vessels   3 

'  Ricord,  Lettres  sur  la  Syphilis,  Paris.  1856,  p.  349. 

^  Virchow,  La  Syphilis  Constitutionelle,  Paris,  i860,  p.  117. 

'  Lancereaux,  La  Syphilis,  Paris,  1866,  p.  384. 

*  More  than  a  hundred  contributions  are  tn  be  found  in  the  literature. 
'  Fagge,  Principles  and  Prac.  of  Med.,  1886,  Vol.  II,  p.  34. 

*  Mracek,  Arch.  f.  Derm.  u.  Syph.  (Ergaenzungshefte),  s.  279  u.  237- 


;  Syphilis  of  the  Heart  137 

Myocarditis  with  or  without  endocarflitis 15 

Peri-  and  endocarditis i 

Diseases  of  myocardial  vessels  and  myocarditis i 

Diseases  of  g-ang-lia,  etc 11 

61 

It  will  be  observed  that  he  found  gummas  in  30,  or  about  50  per 
-cent.,  and  as  many  or  most  of  the  other  forms  may  be  logically  at- 
tributed to  gummas,  it  follows  that  the  lesion  is  the  one  par  excel- 
lence of  the  disease.  This  preponderance  of  gummas  points  out  an- 
other interesting  fact,  viz.,  that  the  disease  is  usually  a  manifestation 
of  late  syphilis,  indeed,  of  the  third  stage.  In  fact,  it  may  be  ex- 
pected as  a  late  event,  perhaps  as  much  as  eight  to  ten  years,  or  even 
more,  after  the  initial  lesion. 

In  rare  cases,  however,  it  may  occur  in  childhood  and  early  youth, 
and  is  sometimes  congenital.  In  150  autopsies  on  infants  with  he- 
reditary syphilis  Mracek  found  cardiac  syphilis  in  four.  Fischer'^ 
has  also  reported  a  case ;  but  they  are  extremely  rare.  WoUstein, 
Pathologist  of  the  Babies'  Hospital  of  this  city,  in  her  large  experi- 
ence has  never  seen  a  single  one. 

As  one  might  suppose,  it  is  more  common  in  the  male  sex,  and  is 
usually  seen  between  the  ages  of  20  and  40.  The  gumma  varies 
in  size.  It  is  usually  found  in  the  ventricles,  but  may  also  occur 
in  the  auricles,  septa  or  papillary  muscles  ;  or  in  fact  anywdiere  in 
the  heart.  It  is  usually  multiple,  and  the  nodules,  as  we  commonly 
recognize  them,  are  from  the  size  of  a  pea  upwards.  It  may  dissolve 
or  break  dov/n  and  discharge  into  the  cavities  of  the  heart  or  outside 
■of  it,  causing  a  cardiac  aneurism.  If  cicatrization  follows  a  gum- 
ma, there  will  be  atrophy  of  muscle  fibres  in  the  adjacent  territory; 
and  if  there  is  a  general  sclerosis  extending  from  the  thickened 
vessels,  there  will  be  general  atrophy  of  the  muscle.  If  the  gumma 
is  near  the  periphery  of  the  organ,  the  sclerosis  will  extend  toward 
the  surface,  and  may  leave  a  point  of  thickening  (milk  patch)  there. 
In  the  same  way  valvular  deformities  may  be  produced  by  the  deposit 
of  a  gumma  in  the  valve.  Its  dissolution,  with  subsequent  pucker- 
ing, from  loss  of  substance  in  the  vafve,  or  a  defect  due  to  a  gumma 
in  a  tendinous  chord  or  papillary  muscle,  may  cause  distortion  of  the 
valve  and  incompetence  or  obstruction,  or  both. 

The  gumma  at  first  is  of  a  pearly  gray  color,  and  enclosed  in  a 
pretty  firm  fibrous  capsule.     If  haemorrhage  ensues,  it  becomes  red 


^Fischer,  Mucnchner  Med.  JVoch..  1904,  51,  s.  652. 


138  Syphilis  of  the  Heart 

or  yellowisli.  proxidoJ  it  iinderg'oes  change  or  lircaks  down  and 
di>char>jcs.  Indcr  these  circumstances,  the  central  material  is  fatty 
or  sticky,  the  latter  when  it  undergoes  a  mucoid  rather  than  a  fatty 
cliaiige.  It  is  this  nuicoid  suhstance  which  sticks  to  the  fingers 
and  gives  its  name  to  the  gummy  tumor. 

V'VA  whatever  the  change  is.  that  is.  whether  it  undergoes  absorp- 
iion  or  discharges  its  contents,  the  ca])sule  contracts,  hardens,  and 
a.^sumes  a  wliitish  color;  and  it"  the  material  has  l)een  discharged 
fiom  the  center,  it  leaves  a  depression,  looking  like  a  depressed  cica- 
trix, from  which  bands  of  fibrous  tissue  radiate  outwards  ;  while  the 
center  is  apt  to  be  stained  of  a  yellow  color. 

j'li  general  these  jieculiar  changes  depend  on  larger  or  smaller 
gummv  tumors,  originating  in  the  walls  of  the  vessels  and  spread- 
mg  thioiighout  the  organ,  along  the  line  of  the  vascular  network. 
The  process  appears  to  be  originally  an  arteritis,  wdiich  begins  in 
the  substance  of  the  vessel  or  its  periphery.  It  is  an  axiom  that 
syphilis  loves  arteries,  so  that,  in  general,  to  them,  rather  than  else- 
where, we  must  look  for  the  original  focus  of  the  syphilitic  mani- 
festation. 

It  follows  from  all  this,  that  gummv  tumors  and  even  aneurisms 
are  apt  to  be  multiple ;  but,  as  already  saitl,  the  difficulty  of  recog- 
ni/ing  any  of  these  conditions,  except  the  gummy  tumor  or  the 
fibroid  infiltration  immediately  connected  with  it,  is  very  great,  so 
th.it  endocarditis,  pericarditis  or  myocarditis  occurring  in  syphilis, 
and  aj-  seen  at  autopsies,  is  likely  to  be  attributed  to  anything  but  the 
constitutional  disease. 

In  fact,  the  problem  of  determining  whether  any  fibroid  infil- 
tiation,  unless  connected  with  a  gummy  tumor,  is  really  syphilitic 
is  to  my  mind  ])ractically  unsolved  at  the  present  time.  Another 
reason  for  failure  in  recognizing  cardiac  syphilis,  clinically,  is  that  it 
is  ovc  of  the  latest  phenomena  of  syphilis,  occurring  many  years 
after  all  external  manifestations  of  the  disease  have  disappeared. 
Neitlier  physician  nor  patient  may  have  any  suspicion  of  it.  In  fact. 
Weber's^  cases  go  to  prove  that  the  cardiac  lesion  may  occur  so  long 
after  every  external  sign  has  gone  that  nothing  except  specific 
treatment  w-ill  reveal  its  true  nature.  In  many  cases  of  heart  syph- 
ilis we  naturally  expect  t(j  find  sclerosis  of  the  coronary  arteries  or 
their  branches,  for  we  know  that  syphilis  is  a  common  cause  of  ar- 
teriosclerosis, and  the  most  frequent  one  of  aneurism.  We  must 
be  careful,  however,  not  to  impute  all  coronary  diseases  to  syphilis. 
It  is  true  that  these  affections  are  often  associated  with  syphilis. 


Weber,  Post-Craduaic,  Nov.,  1903. 


Syphilis  of  the  Heart  139 

Thefe  are,  of  course,  other  causes  of  sclerosis.  Syphilis  may  also 
affect  the  nerves  and  ganglia  of  the  heart,  as  microscopic  examina- 
tions have  shown. 

The  diagnosis,  in  any  instance,  is  mainly  based  on  a  previous  his- 
tory of  syphilis,  usually  in  a  patient  who  has  been  treated  according 
to  the  regulation  methods  with  both  iodides  and  mercurials,  until 
the  manifestations  have  disappeared,  so  that  there  are  no  visible  or 
palpable  signs  of  the  disease  remaining.  In  fact,  it  may  have  lain 
dormant  ten,  twenty,  thirty  or  more  years,  according  to  Weber's 
experience.  Some  of  the  signs  are  as  follows :  Arteriosclerosis, 
a  weak,  intermittent  and  perhaps  frequent  pulse,  dilated  heart  or  an- 
gina, disease  of  the  aorta,  possibly  aneurism,  occasionally  a  valvular 
disease.  If,  in  such  instances,  a  course  of  iodides  and  mercurials 
greatly  ameliorates  or  relieves  the  symptoms,  and  other  possible 
causes  of  cardiac  affections  are  excluded,  the  diagnosis  is  practically 
made. 

The  late  Dr.  Whittaker.-'  in  an  excellent  article  on  this  subject, 
tells  us  how  he  made  a  diagnosis  under  these  circumstances  and 
ciired  his  patient.  The  following  is  an  illustrative  case  from  my 
records : 

Case  XLII.  Syphilis;  Tubercular  Phthisis;  Locomotor  Ataxia; 
Mitral  Disease. — Mr.  A.,  married  and  about  35  years  of  age,  con- 
sulted me  first  in  February,  1897.  He  had  contracted  syphilis  about 
seven  or  eight  years  earlier.  I  found  him  weak,  emaciated  and 
ataxic,  walking  with  great  difficulty  and  hardly  able  to  get  up  or 
down  stairs.  Pulse  hard  and  frequent,  125 — 130.  Respiration  20. 
Temperature  rising  daily  to  101°  F.,  and  more.  Cough  and  abundant 
muco-purulent  expectoration ;  occasional  bacillus  of  phthisis  in  spu- 
tum. Physical  examination  showed  cavities  in  both  lungs  and  a 
dilated  heart.  Apex  in  6th  space,  and  outside  of  nipple.  Mitral 
regurgitant  murmur  carried  to  axilla.  Patient  had  been  taking 
digitalis  daily,  under  medical  advice,  but  it  was  stopped  at  once.  Un- 
der treatment  by  iodides  and  hydriodic  acid  he  improved  so  much 
that  a  modified  series  of  baths  and  exercises  were  given  him  (Xau- 
heim  plan),  with  electricity.  Later  he  was  kept  on  mercurials  and 
iodides  for  a  period  of  two  years,  during  which  he  had  no  heart 
stimulants.  Under  this  treatment  the  lightning  pains  disappeared, 
and  he  gained  in  health  and  strength  to  such  an  extent  that  in  the 
autumn  of  1897  he  was  able  to  resume  his  business,  continuing 
at  it,  with  only  occasional  interruptions,  up  to  the  date  of  his  last 
illness  in  March  of  1899.    At  that  time  he  was  taken  down  with  an 

*  Whittaker,   Tzveniieth  Century  Med.,  Vol.  IV..  p.  369. 


I40  Syphilis  of  the  Heart 

attack  of  acute  gastritis,  to  which  he  succunibed  after  a  few  days' 
iUness.  The  attack  was  superinduced  by  causes  tliat  were  appar- 
ently in  no  way  related  to  the  specific  disease  or  cardiac  manifesta- 
tions. Whether  in  this  instance  the  endocarditis  was  syphilitic  or 
not  I  do  not  know.  So  far  as  my  records  go,  it  was,  except  for 
tuberculosis,  the  only  predisposing  cause  of  which  I  was  aware. 

Without  the  anti-sypliilitic  treatment  the  patient  was  unable  to 
attend  to  his  business,  but  under  the  alternate  use  of  both  iodides 
and  mercurials,  more  especially  the  latter,  he  led  a  fairly  active  life. 
In  this  connection  it  is  interesting  to  know  that  Schuster/"  of  Nau- 
heim,  and  others  have  noticed  the  connection  between  tabes  dor- 
salis  and  heart  syphilis.  I  have  now  under  m\'  care  two  gentlemen, 
one  a  physician,  who  have  both  had  tertiary  s^piiilis  and  have  been 
treated  for  it,  one  by  a  well-known  practitioner.  In  neither  case  did 
the  Xauheim  method  give  the  usual  relief  until  the  patients  were 
put  on  specific  treatment,  when  the  improvement  was  comparatively 
rapid. 

We  are  told  by  Huchard^^  that  aiigi)ia  pectoris  is  a  most  im- 
portant sign  of  cardiac  syphilis.  In  no  cases  collected  by  him,  32 
had  a  syphilitic  history.  If  it  is  true  that  angina  is  essentially  a  dis- 
ease of  the  coronary  arteries,  judging  b}-  analogy,  syphilis,  which 
predisposes  to  coronary  disease,  should  be  an  important  cause  of  an- 
gina.    The  therapeutic  inference  is  obvious. 

Case  XLIII.  Syphilis;  Cirrhosis;  Fatty  Degeneration  of  the 
Heart. — The  following  is  one  of  my  hospital  cases  of  general  syph- 
ilis, with  fatty  degeneration  of  the  heart,  in  which  syphilis  figures 
as  the  only  predisposing  cause :  A  man  of  46  entered  the  hospital  with 
swollen  feet,  cough,  jaundice  and  dyspnoea.  A  soft  systolic  bruit 
was  heard  at  the  apex.  The  heart  was  found  to  be  enlarged.  At 
the  post-mortem  examination  the  pericardial  .sac  was  seen  to  contain 
ID  ounces  of  clear  serum,  and  there  were  several  milk  patches  on  the 
heart.  There  were  no  valvular  lesions.  The  liver  was  cirrhotic 
and  there  was  chronic  diflFuse  nephritis.  At  the  autopsy  the  murmur 
was  attributed  to  the  fatty  degeneration  of  the  heart.  It  is  in  cases 
like  these  where  the  cardiac  lesions  are  possibly  due  to  syphilis,  that 
we  still  lack  conclusive  proof.  It  is  to  be  hoped  that  we  may  soon 
have  some  method,  chemical  or  biological,  by  which  syphilis  can  be 
recognized  at  any  stage.  It  is  not  unlikely  that  the  milk  patches  in 
this  instance  were  continuous  with  syphilitic  sclerosis  of  the  heart 
walls. 

The  occurrence  of  syphilis  as  a  factor  in  heart  disease  is  probably 

"'  Schuster,  Deutsch.  Med.,  Woch..  Oct.  8,  1903.  V  ' 

"  Loc.  Cit.,  p.  798. 


Syphilis  of  the  Heart  141 

not  only  more  frequent  tlian  has  been  sujjposed,  but  the  actual  cause 
of  death  in  many  instances.  Runeberg's^'  statistics,  which  have  been 
widely  read,  indicate  this :  He  found  in  the  experience  of  a  single 
life  insurance  company  that  out  of  734  deaths,  at  least  84,  or  about 
11  per  cent.,  were  of  persons  who  had  contracted  syphilis.  Twenty- 
two  of  these  deaths  were  attributed  to  progressive  paralysis,  and 
33  to  disease  of  the  central  circulatory  system  (that  is,  of  the  heart 
and  aorta ) ,  24  of  the  latter  dying  of  syncope ;  so  that  the  danger  of 
death  from  a  syphilitic  heart  or  aorta  was  greater  than  from 
syphilitic'  disease  of  the  central  nerve  system,  and  sudden  death 
was  tlie  rule. 

In  looking  over  my  private  cardiac  cases  I  find  that  syphilis  was 
positively  present  in  about  5  per  cent.,  and  probably  in  another 
5  per  cent. :  the  inference  being  that  in  cardiac  disease  we  should  sus- 
pect that  syphilis  is  a  factor  in  at  least  10  per  cent. 

The  prognosis  is  bad,  but  not  altogether  so.  If  the  diagnosis 
can  be  made  early  and  the  proper  treatment  instituted,  some  success 
may  be  expected.  Even  in  advanced  cases  where,  for  example,  there 
is  tabes  dorsalis,  improvement  can  sometimes  be  effected,  as  is  shown 
in  Case  No.  XLII.  Yet,  notwithstanding  that  we  may  be  able  to 
remove  the  deposits  by  medicine,  a  something  will  remain,  so  that 
if  the  part  resumes  its  physiological  activity  it  still  may  not  be  sound 
pathologically. 

We  are  obliged  to  conclude,  therefore,  that  cardiac  syphilis  is 
more  common  that  has  been  supposed.  Like  syphilis  of  the  lungs, 
it  exists,  and  the  physician  who  fails  to  appreciate  either  of  them 
falls  short  of  his  duties  as  a  practitioner  of  medicine.  In  fact, 
neither  heart  nor  lungs  should  be  examined  without  always  holding 
in  view  the  possibility  of  syphilis,  as  the  cause  of  the  disease.  Where 
it  may  not  be  possible  to  make  a  positive  diagnosis,  a  probable  one 
can  often  be  reached.  Appropriate  treatment  will  confirm  it.  Car- 
diac syphilis  is  an  insidious  disease,  and  its  manifestations  are  neither 
pronounced  nor  distinctive.  For  this  very  reason  physicians  in 
making  inquiries  and  in  physical  examinations  should  pay  partic- 
ular attention  to  the  subject  of  syphilis.  A  cure  may  be  possible, 
while  relief  is  probable..  Iodides  and  mercurials  are  the  proper 
remedies,  but  mercury  is  the  sheet  anchor.  Sometimes  both  of  them 
must  be  given  for  months  and  even  years,  with  brief  interruptions 
of  a  few  weeks  or  so.  If  in  such  cases  the  physician  fails  to  rec- 
ognize the  existence  of  syphilis,  he  should  not  be  surprised  if  his  pa- 
tient is  carried  off.  without  warning,  from  sudden  heart  failure. 


Rnneberg,  Dcutscb.  Med.  JVoch..  i  11.  2,  1903. 


CiiArrtK  XIII. 

nisiM.ACi-:Mi-:\'rs  oi-  Tin-  iii:.\irr. 

DisplaccnieiUs  eit  ihc  heart  arc  indicated  in  a  general  way  by  the 
position  of  the  apex  beat.  This,  in  the  well  developed  adult  (in  the 
standing-  position,  with  respiration  suspended)  is  about  3"^  inches 
from  the  median  line  and  in  the  5th  left  intercostal  space.  More  accu- 
rately, however,  under  similar  conditions  antl  in  the  male  it  lies  mid- 
way between  the  nijiple  and  the  tip  of  the  xiphoid  ai)pendix,  and  the 
distance  of  lyS  to  2  inches  inside  the  nipple  line.  In  persons  of 
slight  build  the  apex  may  he  <inly  from  2  to  3  inches  from  the 
median  line,  however,  so  that  the  method  of  fixing  T,y2  inches  from 
the  median  line  as  the  normal  point  for  the  apex,  is  obviously  im- 
l^oper. 

A  certain  amount  of  motility  of  the  heart  is  physiological,  be- 
cause while  it  is  fixed  firmly  at  its  base,  by  the  great  vessels,  the 
organ  itself  hangs  loosely  in  the  pericardial  sac.  Thus  if  the  pa- 
tient, after  l\ing  on  his  back,  turns  over  on  the  left  side,  the  apex  will 
usually  be  displaced  an  inch  or  more  to  the  left,  and  sometimes  as 
much  to  the  right,  if  he  turns  over  to  that  side.  In  forced  inspira- 
tion, also,  the  dia])hragni  descends,  carrying  the  heart  downwards, 
while  in  expiration,  the  diai:thragm  moves  upwards,  and  the  apex 
goes  up  with  it.  This  excursion  of  the  diaphragm  may  be  as  much 
•IS  2  inches :  but,  strictly  speaking,  there  is  no  rotation  of  the 
organ. 

In  some  cases  the  impulse  is  l)cst  felt  if  the  patient  leans  over 
forwards.  For  example,  in  pericardial  effusions,  where  the  im- 
pulse is  wanting  it  is  natural  that  gravity  should  cause  the  heart 
10  displace  the  fluid,  and  as  a  matter  of  fact,  when  the  ])atient  leans 
forward,  the  a])ex  comes  nearer  to  the  anterior  wall  of  the  chest. 

Displacements  have  been  divided  into  the  (i)  intrinsic  and  the 
(2)  extrinsic  In  the  intrinsic  the  displacement  is  due  to  the  en- 
largement of  the  ventricles,  the  extrinsic  to  external  causes.  Un- 
donbtedlv  under  certain  conditions,  as  in  uncomplicated  aortic  steno- 
sis, which  has  not  been  compensated,  the  dilated  left  ventricle  op- 
erates to  displace  the  apex  to  the  right.  So  in  well  developed  lobar 
pneumonia,  dilatation  of  the  right  ventricle  will  tend  to  displace 
the  apex  to  the  left.  Such  a  state  of  afifairs,  however,  is  short-lived, 
and  limited  to  the  duration  of  the  conditions  named  ;  nor  is  the 
displacement  of  high  degree.     Yet,  in  exceptional  instances,  as  in 


Displacements  of  the  Heart  14,5 

extreme  general  dilatation,  the  a]jcx  may  assume  a  very  unnatural 
position.  On  the  other  hand,  in  the  extrinsic  form  there  are  very 
high  degrees  of  disi)lacement.  J I  ere  the  heart  may  be  displaced 
in  any  direction,  upzi'ard  or  dozvmvard,  laterally,  furivard  or  back- 
zvard.  The  vertical  and  lateral  displacements  are  the  most  common, 
however. 

The  heart  is  pressed  itpzcard  \)y  gastro-intestinal  distention,  ascites, 
gas  in  the  peritoneal  cavity,  abdominal  tumors,  the  pregnant  uterus, 
even  by  an  enlarged  liver^  or  spleen  ;  or  it  may  possibly  be  drawn  up 
by  the  fibrous  contractions  of  pulmonary  or  pericardial  disease.  Gib- 
son has  reported  the  case  of  a  diabetic,  where  the  upper  margin  of 
the  organ  corresponded  to  the  lower  margin  of  the  4th  left  rib.  In 
this  case  the  lungs  were  also  pushed  upward. 

Often  in  stout  people  simple  distention  of  the  stomach  and  in- 
testines so  presses  up  the  heart  as  to  cause  annoying  dyspncea.  Uut  in 
these,  and  other  slowly  moving  precesses,  the  embarrassment  of  the 
heart  does  not  always  cause  immediate  danger  to  life.  On  the  other 
hand,  in  acute  processes,  such  as  sudden  distention  of  the  peritoneal 
cavity  from  rupture  of  the  intestine,  great  distress  may  ensue  and 
and  death  result,  unless  surgical  relief  is  promptly  given.  Fortu- 
nately in  many  chronic  cases,  like  the  puerperal  and  in  ovarian 
dropsy,  the  abdominal  walls  easily  yield  and  distending  forwards, 
relieve  the  upward  pressure. 

In  some  cases  there  is  dozvnzvard  displacement  of  the  heart,  due 
perhaps  to  thoracic  aneurism,  pulmonary  disease,  tumor  or  pleuritic 
efifusions,  gastroptosis,  or  general  ptosis  of  the  abdominal  organs. 
(Glenard's  disease.) 

Lateral  displacements  are  very  common.  They  may  be  produced 
by  pleurisy  with  effusion,  collapse  or  destruction  of  lung,  cavities, 
pulmonary  diseases,  curvatures  of  spine,  tumors,  or  congenital  dis- 
placements of  viscera.  They  may  not  cause  much  distress,  but 
often  are  sources  of  constant  pain.  Pleurisy  with  eft'usion  is  a  very 
frequent  cause.  As  it  comes  on  slowly  or  rapidly,  so  the  danger  to 
the  heart  is  inconsiderable  or  great.  The  heart  may  be  moved  to 
the  left  or  the  right.  In  right-sided  pleurisy  the  apex  is  carried 
towards  the  left  axillary  line.  In  left-sided  pleurisy,  however,  as  a 
rule,  the  apex  seldom  extends  beyond  the  middle  line.  In  one  in- 
stance, how-ever,  recorded  by  Walshe,  the  apex  was  carried  under 
the  right  nipple. 


^  In  one  of  my  cases  of  enlarged  liver  the  apex  beat  was  seen  to  be  above 
the  level  of  the  nipple. 


144  Displacements  of  the  Heart 

riie  lieart  may  also  be  carri(.(,l  lorwartls  by  tbLiracic  aneurism  or 
by  tumors  of  the  posterior  metliastinum.  It  may  be  displaced  back- 
wards in  pericarditis  with  eftusion,  in  pulmonary  or  pleuritic  dis- 
eases, and  in  tumors  or  abscesses  of  the  anterior  mediastinum. 

In  any  case,  if  the  displacement  is  gradual  the  subjective  symp- 
toms may  be  insignificant ;  if  sudden,  there  may  be  praecordial  press- 
ure, even  angina,  palpitation  and  dyspnoea,  causing  collapse  and  pos- 
sibly death. 

Lateral  displacements  are  also  easily  recognized  by  the  position 
of  the  apex  beat.  Percussion  and  the  discovery  of  the  apex,  either 
by  its  impulse  or  by  the  stethoscope,  makes  the  diagnosis  easy.  It 
may  be  confirmed  by  tlie  X-ra}',  as  in  Case  XCV.  But  prognosis 
and  treatment  ilepend  on  the  causes.  Intrinsic  displacement  calls  for 
the  treatment  of  the  underlying  valvular  condition.  Acute  dilatation 
offers  good  ground  for  hope,  if  the  condition  is  recognized  early 
and  the  projjer  measures  are  taken.  In  chronic  cases  more  or  less 
relief  is  to  be  expected.  These  matters  are  discussed  at  length 
in  the  chapter  on  the  General  Management  of  Heart  Diseases. 

The  prognosis  of  displacement  due  to  extrinsic  causes  depends 
on  the  success  wliicli  attends  the  management  of  the  underlying  dis- 
eases. The  operation  of  thoracentesis  will  give  temporary  relief  in 
pleural  etifusions.  perhaps  it  will  be  curative.  Tapping  for  ascites  will 
also  give  relief.  So  also  will  the  removal  of  an  ovarian  tumor,  or  a 
normal  parturition,  where  dis])lacement  is  the  result  of  pregnancy. 

The  prognosis  when  displacement  is  caused  by  tumors  or  an- 
eurisms is  unfavorable.  In  chronic  lung  affections  no  permanent 
gain  can  be  expected  by  treatment ;  nor  in  chronic  incurable  condi- 
tions, like  an  enlarged  liver.  Where  the  displacement  is  due  to  en- 
largement of  the  spleen,  the  prognosis  is  better.  In  curvature  of  the 
spine  much  relief  is  afforded  by  suitable  exercises.  The  following 
are  illustrative  cases  of  extrinsic  displacement: 

Case  XLIV.  Urcrntia:  Adherent  Pcricardiuui:  Scro-Purulent 
Pleurisy:  DisHaceinenf  of  Heart  to  the  Ri^^ht. — C.  B.  was  ad- 
mitted to  hospital  Jan.  3rd.  1881.  He  was  emaciated,  an?emic  and 
dvspnoeic.  Oedema  of  feet.  Scanty  urine.  Temperature  normal. 
Pulse  112.  Respiration  40.  On  physical  examination  a  large  amount 
of  fluid  was  found  in  the  left  side  of  the  chest.  Apex  of  the  heart 
to  the  right  of  the  sternum.  Under  treatment  the  urine  increased 
to  an  average  of  18  ounces  per  day. 

.A.n  operation  revealed  a  sero-purulent  fluid  in  both  pleural  cavi- 
ties.    The  patient  died  of  uraemia.      At  the  autopsy  100  ounces  of 


Displacements  of  the  Heart  145 

a  sero-purulent  fluid  was  taken  from  the  left  pleural  cavity,  and  15 
from  the  right.    Adherent  pericardium. 

Case  XLV.  Chronic  Pericarditis  and  Endoca/rditis:  Pleurisy 
with  effusion:  Displacement  of  Heart  to  the  Left. — A.  H.,  admitted 
to  hospital  Aug.  2,  1885.  He  was  emaciated  and  anaemic,  com- 
plained of  dyspnoea,  dry  cough  and  debility.  On  examination,  the 
signs  of  pleurisy  with  effusion  were  found ;  the  right  side,  in  the  line 
of  the  nipple,  measuring  18^  inches,  to  163^  of  the  left.  There 
were  also  indications  of  pericarditis.  Apex  of  the  heart  in  the  5th 
space,  in  the  line  of  the  nipple.  Aspiration  drew  off  50  ounces  of 
clear  serum  from  the  right  chest.  The  patient  recovered  from  the  as- 
piration, but  died  10  days  later  of  heart  failure,  due,  it  was  thought, 
to  the  pericarditis.  The  pericardial  sac  contained  34  ounces  of  clear 
serum ;  in  the  right  pleural  sac  were  32  ounces  of  a  similar  serum. 

Displacements  of  the  thoracic  and  abdominal  viscera  are  also 
natural  sequences  of  lateral  curvature,  and  inasmuch  as  the  deform- 
ity is  usually  most  marked  in  the  dorsal  region,  it  is  the  contents 
of  the  thorax  that  are  apt  to  suffer  most.^  In  the  early  stages  of  the 
disease,  or  in  slight  cases,  the  alterations  of  position  or  of  function 
in  the  thoracic  organs  may  be  inconsiderable,  but  in  advanced  de- 
grees of  the  deformity  unnatural  positions  of  these  viscera  may  SO 
seriously  affect  their  functions,  as  to  disturb  both  respiration  and 
circulation. 

The  large  experience  of  Adams'*  led  him  to  say,  in  speaking  of 
the  effect  of  lateral  curvature  on  the  general  health :  "While  no  af- 
fection can  possibly  be  more  variable  as  to  its  general  symptoms 
and  its  influence  upon  the  health  of  the  patient  than  lateral  curva- 
ture of  the  spine,"  and  while  "no  symptoms  such  as  would  interfere 
with  the  general  health  of  the  patient  may  be  present,  even  up  to  the 
middle  period  of  life,  although  the  evil  day  is  put  off,  it  neverthe- 
less arrives  sooner  or  later,  and  the  patient  suffers  from  functional 
disturbance  of  the  thoracic  or  abdominal  organs  to  an  extent  which 
leads  to  the  belief  that  serious  disease  of  these  organs  exists." 

In  regard  to  the  functional  derangement  of  the  thoracic  organs, 
he  further  says :  "In  slight  cases  of  lateral  curvature  of  the  spine, 
when  associated  with  general  debility  and  occurring  in  girls,  it  is 
by  no  means  uncommon  for  the  patient  to  suffer  from  palpitation 
of  the  heart,  with  a  disposition  to  fainting,  etc.,  with  feeble  and  irreg- 
ular pulse."     Adams  adds :     "The  opposite  view,  however,  is  gener- 


^  See  Nezv  York  Med.  Journal,  Sept.  30,  i{ 
*  Curvature  of  the  Spine,  London,   1882. 


146  Displacements  of  the  Heart 

ally  taken  by  those  who  see  but  few  cases  of  spinal  curvature,  and 
the  enfeebled  condition  of  the  general  health,  together  with  the  as- 
sociated functional  disturbances,  are  regarded  as  the  primary  and 
essential  affection,  to  which  the  spinal  curvature  is  merely  second- 
ary;  but."  he  continues,  "in  the  more  severe  cases  of  lateral  curva- 
ture of  long  standing,  where  the  heart  becomes  displaced  and  to 
some  extent,  perhaps,  embarrassed  by  the  contraction  and  deformity 
of  the  chest,  palpitation,  with  some  irregularity  in  its  action,  may  be- 
come a  more  prominent  symptom  and  lead  to  the  suspicion  of  the  ex- 
istence of  heart  disease."  Adams  also  quotes  John  Shaw,  of  London, 
who  stated  that  he  "had  been  consulted  by  several  patients  who  had 
been  treated  for  disease  of  the  heart,  though  all  the  symptoms  were 
caused  by  distortion  of  the  spine."  and  adds.  "I  have  known  several 
patients  about  the  middle  period  of  life,  afflicted  with  severe  spinal 
curvature,  so  impressed  with  the  idea  that  they  were  suffering  from 
disease  of  the  heart  that  the  highest  medical  authorities  failed  to 
remove  such  impression."  And  he  concludes  :  "Many  similar  cases, 
and  several  in  which  the  symptoms  referable  to  the  interference  with 
the  functions  both  of  the  heart  and  lungs  have  been  much  more  se- 
vere, have  been  under  my  observation  in  hospital  and  private  prac- 
tice." As  an  illustration  of  the  unnatural  division  of  the  thoracic 
cavity  in  lateral  curvature,  he  alludes  to  a  specimen  in  the  collection 
of  the  Royal  College  of  Surgeons  in  London,  where  the  space  be- 
tween the  bodies  of  the  vertebrae  and  ribs  w^as  reduced  to  three- 
fourths  of  an  inch. 

Bouvief'  also  speaks  of  a  case  where  the  heart  could  scarcely  find 
room  for  itself  in  the  narrow  space  left  by  the  lung,  and  in  fact  it 
appeared  to  be  forcibly  applied  to  the  thoracic  wall. 

These  statements  from  w^ell-known  orthopaedists,  widely  sepa- 
rated in  locality  and  spheres  of  influence,  go  to  show  that  there  is  an 
established  belief  that  lateral  curvature  tends  to  disturb  the  functions 
of  heart  and  lungs. 

Indeed,  Adams  appears  to  approve  of  Bouvier's  statement  that 
"individuals  thus  affected  rarely  live  to  old  age,  and  fall  victims  either 
to  phthisis  or  heart  disease."  How  far  this  is  true  I  am  unable  to 
say,  but  I  have  seen  a  number  of  cases  in  which  it  seems  to  me  that 
the  curvature  was  the  principal  factor  in  determining  cardiac  and, 
associated  with  it,  pulmonary  disease.  Conversely,  I  may  add,  I 
have  seen  improvement  in  the  curves  of  the  spine,  and  correspond- 
ingly,   an    improvement    in    the    position    of    the    heart,    so    favor- 


'  Legons  cliniques,  Paris,  1858,  p.  145. 


Displacements  of  the  Heart  147 

ably  affect  the  circulation,  respiration,  and  general  health  that 
I  am  disposed  to  believe,  with  Adams,  that  the  lateral  curvature 
is,  in  some  cases,  at  least,  the  fons  et  origo  of  the  functional 
disturbance,  rather  than  the  cachexia  which  is  so  apt  to  attend  it. 
My  experience  has  been  chiefly,  but  not  altogether,  confined  to  girls 
between  the  ages  of  twelve  and  twenty-four.  Lateral  curvature 
is  comparatively  infrequent  in  boys  and  young  men.  The  chief 
curve  I  have  usually  found  in  the  dorsal  region  and  to  the  right. 
The  heart  has  in  all  these  cases  been  displaced,  the  apex  varying  in 
position  from  a  point  three-fourths  of  an  inch  to  the  right  of  the  nip- 
ple to  a  point  an  inch  to  the  left  of  it.  I  have  found  the  usual 
difficulty  in  determining  the  causes.  Phthisis,  pleurisy,  especially 
of  the  suppurative  form,  post-scarlatinal  paralysis,  rickets,  and  the 
carrying  of  unusual  weights  have  appeared  to  be  determining  causes. 
While  pain  is  an  acknowledged  sign  of  curvature,  I  have  not  found 
it  constant  or  confined  to  any  special  locality.  It  may  be  referred  to 
the  spine,  or  to  the  parietes  of  the  chest  or  elsewhere.  It  is  usually 
on  the  side  of  the  principal  curve.  Palpitation  and  dyspncea  are  not 
uncommon. 

My  general  plan  of  treatment,  varying  according  to  individual 
cases,  has  been  the  employment  of — 

1.  Resistance  exercises  with  forcible  pressure. 

2.  Carbonated  brine  baths. 

3.  Massage. 

4.  Faradism. 

5.  Nutrients. 

My  svstem  of  exercises  is  a  little  on  the  lines  of  the  system 
laid  down  by  Bernhard  Roth,  of  London.*'  I  give  his  plan  in  brief 
in  order  to  compare  it  with  my  own.     It  is  as  follows : 

1.  The  patient  lies  on  the  back,  with  arms  to  the  sides ;  hands 
supinated.      Several  deep  inspirations  are  then  taken. 

2.  The  patient  in  the  same  position  extends  the  arms  above  the 
head  and  inspires  deeply  several  times. 

3.  In  the  same  posture  the  patient  rotates  the  head,  and  flexes  it 
laterally. 

4.  In  the  same  position  the  arm  is  circumducted. 

5.  In  the  same  position  one  hip  is  circumducted,  then  the  other, 

6.  In  the  same  position  the  patient  extends  the  arms  forward 
and  backward. 

7.  The  patient  lies  prone  and  circumducts  one  hip,  then  the  other. 


'^British  Med.  Journal,  May  13,  1882. 


148  Displacements  of  the  Heart 

8.  The  patient  now  sits  on  the  couch  ami  the  ankle  is  circum- 
ducted. 

9.  The  same,  but  the  operator  resisting. 

10.  The  patient  sits  astride  a  narrow  bench  or  couch  prepared  for 
tlie  purpose  and  flexes  the  trunk,  the  oj)erator  resisting. 

11.  The  patient  grasping  pegs  on  a  pole,  the  operator  rotates  the 
pelvis. 

12.  The  patient  lies  on  a  couch  with  the  head  projecting,  while  the 
head  is  flexed  by  the  operator. 

These  exercises  appear  to  be  in  the  right  direction,  but  are  mild 
as  compared  with  my  own.  They  would  be  chiefly  applicable,  I 
think,  in  the  earlier  stages  of  the  disease  or  in  slight  curves.  I 
should  prefer  the  more  elaborate  and  scientific  method  laid  down  by 
Dr.  Sayre'  to  Roth's  system.  Assuming  that  the  scheme  of  exer- 
cises should  vary  somewhat  according  to  the  nature  and  extent  of 
the  curve,  I  now  give  my  ordinary  method  in  the  fully  developed 
double  curve. 

The  system  is  mainly  that  of  Professor  Hartelius,  of  Stockholm, 
as  modified  by  Dr.  H.  V.  Barclay  and  myself.  The  first  step  before 
each  exercise  is  to  make  the  patient  assume  a  posture  that  in  itself 
tends  to  reduce  the  deformity,  and  have  this  position  maintained  so 
far  as  possible  during  the  exercises. 

1.  The  patient,  usually  a  young  girl,  standing  with  the  hands 
to  the  side,  raises  both  arms  (fully  extended)  laterally  upward,  so 
as  to  be  parallel.  At  the  same  time  she  raises  herself  on  her  toes. 
The  arm  movement  elevates  the  scapulae  and  the  ribs,  pulls  on  the 
spinous  processes  of  the  vertebrae,  turns  them  upward  and  toward 
the  median  line,  and  in  so  doing  elongates  the  spine.  Put  a  patient 
with  this  special  deformity  on  a  measuring  block,  let  her  go  through 
this  motion,  and  the  spine  will  be  seen  to  elongate  perceptibly.  I 
have  seen  it  elongate  two-tenths  of  an  inch.  This  movement  of  rais- 
ing the  body  on  the  toes  tends  not  only  to  elongate  the  whole  body, 
but  also  to  correct  the  position  of  the  pelvis. 

2.  The  patient,  resting  against  a  suitable  support,  such  as  the 
horizontal  bar  of  the  gymnasium,  applying  the  front  of  the  pelvis  to 
the  bar,  extends  the  arm  corresponding  to  the  dorsal  concavity  up- 
ward, the  operator  resisting.  The  low  shoulder  is  thus  raised,  while 
the  dorsal  and  all  compensatory  curves  in  lumbar  and  cervical  re- 
igons  are  more  or  less  straightened  out. 

3.  The  patient,  standing  in  the  same  position  and  with  the  same 


A^.    Y.   Med.  Journal,   Nov.,   1881. 


Displacements  of  the  Heart  149 

support,  places  behind  her  head  the  hand  of  the  arm  corresponding 
to  the  dorsal  concavity.  The  other  hand  grasps  the  hip  of  the  other 
side.  Now  the  patient  flexes  her  body  at  the  hip  joint,  and  then  erects 
herself,  carrying  the  body  a  little  beyond  the  vertical  line.  The 
operator  stands  behind,  places  his  hands  on  the  convexity  of  the 
dorsal  and  lumbar  curves  and  makes  lateral  pressure,  resisting  the 
erection  of  the  body. 

By  this  method  the  patient,  having  her  spine  supported,  and  in 
a  measure  straightened  by  the  operator,  the  erectors  of  the  spine  and 
the  lumbar  and  gluteal  muscles,  are  brought  actively  into  play, 

4.  The  patient  now  suspends  herself  by  the  hands  from  the  ordi- 
nary horizontal  bar,  which  is  raised  at  one  end  a  peg  or  two  higher 
than  the  other,  so  that  when  the  patient  hangs  by  both  hands  the  low 
shoulder  is  raised.  The  weight  of  the  body  is  now  thrown  to  the 
side  of  the  convexity,  taking  the  strain  off  the  muscles  over  the 
convexity,  while  the  spine  is  more  or  less  straightened  by  the  weight 
of  the  body  and  extremities.  In  this  position  the  patient  flexes  the 
head  backward,  the  operator  resisting.  This  latter  movement  tends 
to  reduce  the  secondary  curve  in  the  cervical  region,  by  bringing  the 
muscles  of  the  neck  into  play  equally  on  both  sides. 

5.  The  patient  now  places  herself  prone  on  a  flat  table  with  the 
arm  corresponding  to  the  dorsal  concavity  stretched  forward.  She 
then  raises  the  corresponding  leg  and  opposite  shoulder.  This  exer- 
cise flattens  the  "hump"  in  the  back.  Under  this  combined  move- 
ment the  dorsal  curve  recedes  very  perceptibly  during  the  exercise 
in  the  direction  of  the  median  line. 

6.  The  patient  lies  in  a  semirecumbent  position  on  a  couch  with 
the  legs  hanging  over  the  extremity.  The  arm  on  the  side  of  the 
dorsal  concavity  is  placed  behind  the  head ;  the  other  hand  grasps  the 
opposite  hip.  The  operator  now  fixes  the  patient's  knees,  while 
she  erects  her  body. 

7.  No.  7  is  a  repetition  of  No.  3.  but  in  a  sitting  position,  the 
knees  being  supported  in  front.      This  support  steadies  the  pelvis. 

8.  The  patient  on  the  couch,  with  the  upper  hand  over  the  head, 
lying  on  the  side  corresponding  to  the  lumbar  concavity,  raises  the 
leg  as  far  as  possible.  This  movement,  which  may  be  resisted, 
tends  to  eradicate  the  lower  curve. 

9.  The  patient  sitting  on  a  chair  with  her  body  bent  forward, 
with  spine  as  straight  as  possible,  extends  the  arm  corresponding  to 
the  dorsal  concavity  upward,  while  the  other  arm  is  carried  down. 
These  movements  are  done  simultaneously,  the  operator   resisting 


150  Displacements  of  the  Heart 

each  movement.  Then  tlie  arms  resume  the  original  position  with- 
out resistance.  Tlie  muscles  of  the  cervical  region  are  exercised  by 
the  ascending  arm  and  the  dorsal  muscles  by  the  descending  arm. 

10.  The  patient  in  the  standing  position  raises  the  straightened 
arm  corresponding  to  the  dorsal  concavity  to  the  perpendicular. 
The  other  arm,  still  straight,  is  carried  backward  and  inward.  These 
movements,  like  those  of  No.  9.  tend  to  straighten  dorsal  and  cervical 
curves.      They  should  be  carried  to  the  limit. 

11.  The  patient,  suspended  from  the  bar  by  the  hands,  raises  both 
knees.  The  abdominal  and  psoas  muscles  are  brought  into  play,  the 
bodv  being  held  in  a  favorable  position. 

12.  The  patient,  suspended  from  the  bar,  extends  both  legs 
toward  the  side  of  the  lower  convexity.  This  exercise  tends  to 
straighten  the  lumbar  curve. 

13.  The  patient,  standing  with  leg  of  side  corresponding  to  the 
lumbar  convexity,  in  front,  and  leaning  forward,  carries  both  arms 
backward  and  inward  to  the  limit.  This  exercise  carries  the  shoul- 
der blades  toward  the  spine,  and  tends  to  remedy  their  false  position. 

14.  The  patient,  lying  prone  across  a  narrow  table,  with  the  arm 
corresponding  to  the  dorsal  concavity  extended,  the  other  hand  on 
the  corresponding  hip,  both  ankles  being  fixed  by  the  operator,  erects 
the  trunk  several  times  successively. 

15.  The  patient,  suspended  from  the  bar,  separates  the  extended 
legs,  under  resistance.  This  movement  tends  to  lessen  the  lower 
curve. 

16.  The  patient,  lying  on  a  table,  and  on  the  side  corresponding 
to  the  lumbar  concavity,  with  the  trunk  extended  beyond  the  edge  of 
the  table,  the  ankles  being  fixed  by  the  operator,  with  the  arm  of  the 
depressed  shoulder  extended  over  the  head,  carries  the  trunk  upward 
to  the  limit.  This  exercise  is  very  effectual  in  straightening  the 
lumbar  curves,  while  the  extended  arm  tends  to  straighten  the  dorsal 
curve. 

In  the  beginning,  or  with  feeble  patients,  these  movements  may 
require  assistance  by  the  operator. 

In  the  majority  of  cases  there  is  advantage  in  using  physical  force 
in  the  reduction  of  the  deformity.  The  "hump"  should  be  pressed 
down  forcibly  when  the  patient  is  lying  prone  on  a  hard  surface.  I 
have  never  known  this  method  to  give  pain ;  in  fact,  is  is  agreeable 
to  the  patient. 

Forcible  correction,  the  redressement  force  of  the  French,  has 
been  recommended  and  resorted  to  by  various  orthopaedists.    Indeed, 


Displacements  of  the  Heart  151 

there  are,  as  is  well  known,  appliances  adapted  for  forcible  correc- 
tion. Barwell**  has  described  a  method  which  he  calls  rhachilysis. 
My  experience  indicates  that  if  the  operator  is  strong  enough,  and 
can  give  the  requisite  time,  forcible  correction  can  be  accomplished 
with  a  fair  degree  of  success  by  manual  means  without  the  assistance 
of  any  mechanical  appliance.  But  it  is  not  unlikely  that  mechanical 
contrivances,  for  forcible  correction,  may  be  used  with  advantage  in 
correcting  certain  classes  of  these  deformities,  in  conjunction  with 
resistance  exercises  and  manual  pressure. 

If  there  is  also  Pott's  disease,  or  a  reasonable  suspicion  of  it,  and 
such  cases  will  confront  us,  forcible  correction  would,  of  course,  be 
a  very  improper  procedure  in  connection  with  resistance  exercises. 

Forcible  reduction  rests  the  overstretched  muscles  over  the  con- 
vexity and  reestablishes  the  tone.  The  projecting  capulse  will 
sink  toward  the  normal  position. 

Massage  to  the  muscles  of  the  back  is  not  only  a  valuable  ad- 
junct, but  is  enjoyed  by  the  patient.  It  should  be  given  when  the 
patient  is  lying  with  the  back  bared  upon  a  well-upholstered  couch, 
and  at  the  end  of  the  exercises. 

The  faradaic  current  may  be  applied  occasionally  during  the  entire 
course  of  treatment.  It  should  be  employed  for  a  few  minutes  only, 
so  as  to  actively  contract  the  muscles  of  the  back.  As  in  any  disease, 
each  patient  must  be  treated  with  a  view  to  the  individual  case,  but 
the  methods  described  are  those  that  are  applicable  to  ordinary  un- 
complicated cases  with  the  S-shaped  curve. 

The  use  of  carbonated  brine  baths  is  of  material  aid  in  the  treat- 
ment, the  results  being  more  rapidly  attained  when  baths  and  exer- 
cises are  combined.  In  private  practice  they  should  not  be  neg- 
lected. 

I  advocate  the  use  of  the  warm  carbonated  brine  baths  of  mod- 
erate strength  during  the  entire  course  of  treatment.  The  strength 
of  the  brine  should  be  from  three-fourths  per  cent,  to  one  per  cent, 
and  of  the  carbonic-acid  gas  from  one-fourth  to  one-half  per  cent. 

The  stronger  carbonated  baths  applicable  for  chronic  valvular 
diseases  of  the  heart  are  not  advisable. 

In  a  majority  of  cases  I  use  (to  supplement  the  treatment)  tonics, 
such  as  iron  and  strychnine,  and  nutrients,  such  as  cod-liver  oil  and 
the  malt  extracts,  and  I  continue  them  for  long  periods.  Some  prep- 
aration of  malt  I  find  desirable  in  nearly  all  of  these  cases. 

The  following  are  illustrative  cases : 


Lancet,  April  27,  1889,  p.  831. 


152 


Displacements  of  the  Heart 


Case  XLl'l.  Spi)ial  Lurraturc :  .bucinia;  Cardiac  Displace- 
ment; Corpulence. — Miss  H.,  ag^ed  twenty-four  years.  Havana,  Cuba, 
a  young  lady  of  large  build  ;  boigbt  bve  feet  six  inches  and  a  half, 
weighing  about  a  hundred  and  sixty-three  pounds,  came  to  me  for 
treatment  July  lo,  1898,  wearing  a  spinal  brace. 

September  i,  1898. — On  examination  it  was  found  that  she  had, 
on  standing,  the  usual  lateral  curve  to  the  rigiit  in  the  dorsal  region ; 

k 


S«pt.  1,  'M 
Dec.  2,  '»8 


J 


I  "I  I 


H1- 


1 1 

/ 


Sept.  1.  '98 
-Dec.  1. 'M 


I  I 
;  I 
I 


n 

I  I : 

I  \ 


—  Dec.  8,  ")i 
.--Sept.  1,  •»« 


..(•4. 


il 


\  N.^xDec.  J,  08      /    / 


...V\-*--- 


!     ^x*H(^Hfr  Nov.  11,/ 


U.H. 


Oct.  S.  'M 


Fig.  16. 


Fig.  17. 


pelvis  rotated  and  tilted.  Left  breast  unduly  prominent.  Pale  and 
anaemic.  An  excess  of  flesh,  chiefly  about  the  waist  and  hips.  Short- 
winded  on  slight  exertion,  with  deviation  of  about  an  inch  and  a  half 
from  a  straight  line  in  the  interscapular  region,  and  deviation  of 
an  inch  to  the  left  in  the  lumbar  region.  Apex  of  heart  an  inch 
below  the  nipple.  Patient  given  iron  and  strychnine  and  the  brace 
removed. 

October   19. — One-half  per  cent,  carbonated  baths  given  twice 


Displacements  of  the  Heart 


153 


a  week.  Resistance  exercises  daily  under  direction.  Massage  and 
electricity  to  spinal  region. 

November  11. — Three-fourths  per  cent,  carbonated  baths  once 
a  week. 

December  20. — Under  this  treatment,  continued  for  three  months, 
though  the  course  was  interrupted  by  an  attack  of  influenza,  the 
spinal  deformity  was  so  far  rectified  that  the  greatest  deviation  from 
the  normal  line  on  standing  was  only  three-quarters  of  an  inch  in  the 
dorsal  region,  and  in  the  lumbar  region  three-eighths  of  an  inch. 

January  2,  1899. — Apex  three  inches  from  the  median  line  and 
one  from  the  intermammary  line.  The  patient  was  now  suddenly 
summoned  to  Havana.  She  also  lost  about  fifteen  pounds  in  four 
months,  a  little  less  than  four  pounds  a  month,  and  was  greatly  im- 
proved in  her  physical  condition. 

It  will  be  seen  by  Fig.  16  that  while  the  spine  was  being  straight- 
ened the  heart  (Fig.  17)  was  gradually  carried  inward  toward  the 
median  line.    The  apex  was  brought  inwards  2^  inches. 


Vl-;— Apr.»,-» 
j/ J      /-.-Nov.  13, '98 


. .  Mar.  13, '» 


Fig.  18. 


Fig.  19. 


154  Displacements  of  the  Heart 

After  the  treatment  had  been  begun  the  brace  was  entirely  dis- 
pensed with. 

Ca^e  XLVII.  Lateral  Cnn-aturc ;  Cardiac  Displacement. — J.  C, 
a  patient  sent  to  me  by  Dr.  E.  S.  Hok,  November  13,  1897.  Age,. 
16  years;  weight.  ii3'4  pounds;  height  standing,  58J/2  inches;  sit- 
ting, 31  inches;  chest,  29 — 31.5.  Curvature  of  the  spine  noted 
about  five  years  ago.  Had  pneumonia  and  pleurisy  since  the  curva- 
ture began ;  had  sore  throat  often,  so  had  brothers  and  sisters ;  was 
feeble  as  a  child ;  had  the  common  dorsal  curve  to  the  right.  Left 
breast  prominent.  Often  had  pain  in  left  side  of  chest.  The  left  hip 
higher  than  the  right.  The  anterior  superior  spine  of  left  side  lower 
and  more  forward.  Not  short-winded ;  no  thoracic  pain,  but  insom- 
nia. Had  worn  a  brace  about  two  years.  An  hour  of  resistance 
exercises  were  given  her  daily  under  my  directions  for  about  nine 
weeks,  and  then  afterwards  three  times  a  week.  The  improvement 
in  the  curve  and  in  the  position  of  the  heart  are  shown  by  Figs.  18 
and  19.  Patient  broadened  the  chest  under  treatment  an  inch  and' 
a  quarter,  and  had  an  inch  and  a  fifth  more  expansion.  Lost  twO' 
pounds  in  weight,  but  improved  greatly  in  physical  appearance. 

Ca^e  XLVIII.  Spinal  Curvature ;  Moderate  Cardiac  Displace- 
ment.— K.  G.,  aged  13  years;  height,  57.5  inches.  Two  years  agO' 
noticed  a  crook  in  her  back ;  thought  it  came  from  carrying  an  infant,, 
possibly  from  a  fall  that  caused  depressed  fracture  of  her  skull. 
Often  had  pain  in  right  side.  Left  breast  most  prominent.  Left  hip 
highest ;  left  anterior  superior  spine  most  forward.  Wore  a  brace 
about  six  months  ;  took  it  ofif  during  the  gymnastic  treatment  and 
felt  better  without  it.  The  diagram  illustrates  the  results  under  re- 
sistance exercises.     (See  Figs.  20,  21  and  22.) 

In  this  case,  and  in  Case  XLIX,  the  tracings,  kindly  taken  by  a 
well-known  surgeon  of  the  Orthopaedic  Hospital,  must  be  studied' 
in  connection  with  other  measurements.  The  tracing  of  May  8, 
1899.  shows  an  apparently  excessive  deformity,  but  measurements- 
made  in  this  way,  as  in  fact  all  systems  of  measuring  these  deformi- 
ties, are  more  or  less  misleading,  even  Avhere  they  are,  as  in  this  in- 
stance, quite  accurate.  In  this  particular  tracing  the  deformity  is^ 
exaggerated  by  the  fulness  of  the  muscles,  which  by  exercise, 
massage,  and  electricity  had  greatly  increased  in  size.  But  Fig. 
20  shows  that  in  this  instance  the  compensatory  curves  in  the  lumbar 
and  cervical  regions  were  improved,  and,  in  fact,  that  there  had  been 
a  progressive  improvement  in  all  the  curves. 

Case  XLIX.    Spinal  Curvature;  Rigidity  of  Spine;  Rickets;  De- 


Displacements  of  the  Heart 


155 


bility.—L.  F.,  aged  16  years;  height,  52.6  inches  standing,  28  inches 
sitting;  weight,  81  pounds.  The  following  history  was  kindly  fur- 
nished by  Dr.  Ethel  D.  Brown,  under  whose  observation  she  came. 


Jan.  18,  'DO 

Feb.  20,  "90 


....  Mar.  13,  •» 


Mar.  13,  'W 
Feb.  20,  'W 
Van.  18, '99 
-•Apr.«9, '99 


\\ 


v\ 


I  Mar.  13,  '99    ; 
Feb.  20,  '99 


K.  G 


■Right 


K.G. 


Fig.  20.  Fig.  21. 

Fig.  22. 

and  by  whom  she  was  first  seen  February  14,  1895.  Patient  as  a  baby 
was  weak,  and  sickly  as  a  young  child.  The  trouble  had  only  been 
noticed  bv  the  family  a  few  weeks  earlier  than  the  date  mentioned. 


156 


Displacements  of  the  Heart 


The  first  symptoms  she  complained  of  were  of  pain  in  the  lower  part 
of  the  spine,  and  a  tired  fecHng.  Then  the  mother  noticed  that 
one  shoulder  was  larger  than  the  other.     Even  at  that  time,  ten 


Dec.  tl,  'M 
Jan.  30,  'M 

Apr.  21,  ■99 


/■// Jan.  30,  'W 

//■/ Dec.  a, '38 

Ifjt Apr.  21,  '99     Q'  ,*  - 


i 


Fig.  23. 


:   :    Dec.  n,  '9« 

;    Apr.  26,  '99 
Mar.  13,  '99 
Jan.  30,  '99 


I.  F. 


Fig.  24. 


years  ago,  the  spine  was  quite  rigid.  The  greatest  convexity  of  the 
deformity  was  toward  the  right,  opposite  the  sixth,  seventh  and 
eighth  dorsal  vertebrae,  the  deviation  being  at  the  highest  point  half 
an  inch  from  the  median  line,  approximately.  Considerable  rotation. 
Left  shoulder  slightly  lower.  The  patient  was  put  on  tonics  and 
given  exercises  from  the  above  date  until  the  autumn,  three  times 
a  week,  except  for  a  few  weeks  when  she  was  in  the  country.  In 
the  autumn  she  left  to  go  to  the  country,  the  parents  preferring  to 
have  her  wear  a  brace,  to  taking  the  exercises. 

Patient  had  had  scarlet  fever.  The  principal  cause  of  the  dis- 
ease was  rickets.  Patient  had  not  complained  of  palpitation,  was  not 
short-winded,  but  suffered  from  frontal  headache.  Pelvis  rotated 
and  tilted.  The  crest  of  the  left  ilium  was  about  an  inch  higher  than 
the  other,  while  the  anterior  superior  spine  was  turned  downward 
and  thrown  forward.  On  January  13th  patient  was  wearing  a 
brace.  She  wore  one  for  a  while,  when  tired,  but  has  now  totally 
dispensed  with  it.  The  patient  was  put  on  maltzyme,  and  later  on 
maltine,  and  has  been  gradually  improving  in  her  general  health. 


Displacements  of  the  Heart  157 

May  16,  1899. — Height,  53  inclics  ;  weight,  82^4  pounds.  Patient 
has  gained  an  inch  and  a  half  in  the  chest  measurement,  and  two 
inches  and  three-quarters  in  expansion.  The  diagrams  No.  23  and 
No.  24  show  the  changes  under  treatment.  The  curves  are  straight- 
ening a  little,  while  the  heart's  apex  has  moved  inward. 

This  case  was  selected  as  a  bad  one,  in  which  little,  if  anything, 
was  to  be  expected ;  indeed,  such  was  the  deficiency  in  height,  weight, 
and  bodily  strength,  and  so  great  the  rigidity  of  the  spine,  with  ex- 
ceeding deformity,  that  the  patient  was  thought  a  typical  one,  in 
which  to  test  the  value  of  this  method  in  bad  cases.  In  fact,  an 
English  authority,^  when  asked  whether  his  exercises  would  benefit 
this  particular  case,  replied  that  he  would  not  think  of  using  them. 

The  case  is  also  remarkable  in  several  other  ways.  No  baths 
were  given.  The  treatment  was  merely  resistance  exercises  with 
forcible  pressure  and  nutrients. 

In  measuring  a  spinal  deformity  I  let  the  patient  stand  with  the 
feet  together,  hands  to  the  side,  and  shoulders  thrown  back,  the  head 
and  body  being  held  in  as  erect  a  position  as  possible.  I  then  trace 
the  spinous  processes,  the  angles  of  the  scapulae,  and  the  levels  of 
the  crests  of  the  ilia  on  the  bare  skin  with  a  dermographic  pencil  and 
take  off  a  tracing  with  the  ordinary  vegetable-fibre  tissue  paper  used 
by  artists.  Of  course,  antero-posterior  curves  do  not  show  by  this 
method,  and  yet,  I  may  incidentally  add  here,  that  antero-posterior 
curves  are  apt  to  be  greatly  improved  during  treatment,  as  shown 
by  the  "popping  up"  of  spinous  processes  which  at  first  may  have 
been  buried  out  of  sight. 

But  while  I  have  adopted  the  method  of  measuring  the  amount 
of  curves  as  mentioned,  I  have  not  relied  wholly  on  it,  but  have,  as  al- 
ready stated,  supplemented  it  by  the  lead  tracings,  as  shown  by  Fig. 
22  and  also  by  photographs  and  X-ray  pictures.  As  regards  the  scap- 
ulae, it  will  be  seen  from  the  paper  tracings  that  the  results  of  this 
treatment  are  that  the  inner  borders  are  brought  nearer  the  spinal 
column,  and  assume  more  nearly  the  vertical  or  normal  line. 

It  is  quite  unnecessary,  I  feel  sure,  for  me  to  state  here  a  fact 
widely  recognized  by  orthopaedists,  that  every  system  of  measure- 
ment heretofore  devised  has  proved  more  or  less  unsatisfactory.  A 
few  of  the  objections  are  as  follows:  Photography  rarely  gives  one 
a  sufficiently  distinct  picture  of  the  deformity.  X-ray  pictures  are 
difficult  to  make.  Lead  tracings  may  exaggerate  the  deformity, 
and  are  therefore  deceptive. 

The  method  I  employ  is  also  apt  to  be  misleading,  I  will  admit, 

'Roth. 


158  Displacements  of  the  Heart 

especially  if  the  patient  does  not  stand  as  erect  as  possible ;  but  it  is 
a  simple  one,  and  if  carefully  carried  out,  is  reasonably  accurate. 

It  must  not  be  thought  that  I  am  inveighing  against  spinal  sup- 
ports. I  have  used  them  in  lateral  curvature  at  various  times  in 
my  practice,  and  have  been  satisfied  with  the  results  they  have  given. 
But  a  support  is  palliative  rather  than  curative.  Often  the  patient 
finds  that  he  is  gradually  getting  worse,  notwithstanding  his  sup- 
port. The  method  I  have  advocated  has,  I  hold,  a  much  wider  ap- 
plication, and  is  more  scientific.  It  is  more  or  less  applicable  to  all 
stages  of  the  deformity,  and  is  capable  of  yielding  good  results,  in 
remedying  both  the  curvature  and  the  displacement  of  the  viscera, 
provided  the  patient  is  willing  and  able  to  cooperate  with  the  phy-' 
sician.  While  little  benefit  may  be  obtainable  by  this  method  in  old 
cases,  or  where  there  is  considerable  rigidity,  I  am  satisfied  that  it  is 
capable  of  doing  something  for  circulation  and  respiration,  even 
in  them. 

Gymnastic  exercises,  however,  such  as  are  given  for  lateral  curva- 
ture in  the  ordinary  perfunctory  manner  in  schools  and  gymnasiums, 
will  not  accomplish  much,  if  the  patient  is  a  delicate  subject,  or  the 
case  is  advancing  rapidly.  Special  exercises  adapted  to  special  de- 
formity are  requisite.  Resistance  exercises  also  are  needed,  and 
with  them  forcible  pressure. 

Briefly,  treatment  by  the  method  advocated  is  the  one  that  gives 
the  largest  promise  of  good  results  in  lateral  curvature.  Spinal  sup- 
ports are  chiefly  useful  in  mild  cases  as  temporary  expedients,  or  as  a 
last  resort.  Three  of  the  patients  w^hoses  cases  are  here  given  are 
still  under  my  care,  taking  from  time  to  time  courses  of  exercises, 
which  invariably  relieve  their  cardiac  symptoms. 


Chapter  XIV. 

PERICARDIAL    DISEASES.^ 

Inflammations  of  the  pericardium  are  closely  related  to  the  parts 
it  covers.  In  a  record  of  forty  hospital  and  private  cases,  thirty-three 
were  associated  with  diseases  of  the  heart  itself,  or  with  the  roots 
of  the  great  vessels  contained  in  the  sac.  Pericarditis  is  most  fre- 
quently due  to  some  constitutional  disease,  like  inflammatory  rheuma- 
tism or  Bright's  disease ;  less  often  to  a  distinctive  disease,  such  as 
tuberculosis,  septicaemia  or  scarlatina.  There  may  be  other  causes, 
such  as  cold  or  an  injury.  From  an  etiological  point  of  view,  it  is 
convenient  to  divide  pericarditis  into  the  primary  (so-called  idio- 
pathic form),  and  the  secondary. 

The  primary  form  is  rare,  but  cold  is  certainly  a  cause  of  it,  and 
so  are  injuries  of  various  sorts.  It  is  a  well-known  fact  that 
needles,  pins  and  other  foreign  substances,  that  have  been  accident- 
ally swallowed,  may  find  their  way  into  the  pericardium,  causing 
acute  pericarditis. 

Secondary  pericarditis  occurs  in  from  20  to  70  per  cent,  of 
acute  rheumatic  affections.  Next  in  line,  as  a  casual  factor,  is 
chronic  nephritis.  Following  in  order  of  frequency  is  sepsis,  usually 
from  puerperal  fevers  or  bone  diseases ;  then  come  pneumonia,  scar- 
let fever,  measles,  typhoid,  smallpox  and  malignant  endocarditis. 
So  much  for  the  infective  diseases.  Or  it  may  be  due  to  such  dys- 
crasias  as  scurvy,  diabetes  or  alcoholism.  Then,  it  is  not  uncommon 
to  have  the  disease  a  continuation  of  more  remote  affections. 
Thus,  pleurisy  may  extend  into  the  pericardium,  producing  peri- 
carditis. 

In  forty  of  my  cases,  as  taken  from  my  tables,  the  causes  are 
given  in  thirty-six.  They  are  as  follows:  Rheumatism,  thirteen; 
chronic  nephritis,  eight ;  tuberculosis,  three ;  pneumonia,  two ;  sep- 
ticaemia, two ;  extension  of  disease,  two;  alcohoHsm,  two;  syphilis, 
one  ;  scarlatina,  one  ;  malignant  endocarditis,  one  ;  cold,  one. 

Pericarditis  is  found  at  all  ages.  It  even  occurs  in  foetal  life. 
For  some  reason,  which  is  not  apparent,  males  are  more  subject  to 
it  than  females.  Of  my  forty  cases  there  were  twenty-nine  males, 
and  only  eleven  females. 


Originally  published  in  the  Med.  Times,  April,  1899. 


l6o  Pericardial  Diseases 

It  is  common  to  make  the  following  divisions  of  pericarditis : 

1.  Acute,  plastic  or  dry. 

2.  Pericarditis  with  effusion. 

3.  Chronic  atlhesive  pericarditis    (adherent   pericardium). 

As  a  matter'  of  fact,  these  varieties  run  into  one  another. 

Pericarditis  may  occur  in  small  or  large  areas.  It  may  be  con- 
fined to  a  very  limited  space,  or  may  involve  the  whole  serous  mem- 
brane. A  few  threadlike  bands  may  stretch  over  from  the  visceral 
to  the  parietal  layer  of  the  pericardium  ;  or  the  tw^o  opposing  surfaces 
may  be  covered,  rub  against  one  ancjther,  or  become  attached.  Fric- 
tion ma\'  cause  portions  of  the  tibrine  of  which  the  plastic  deposit  is 
formed,  to  be  separated.  These  portions  will  then  fall  to  the  bottom 
of  the  cavity,  to  be  absorbed,  or  remain  and  undergo  some  sort  of  de- 
generation. In  tuberculous  pericarditis  there  will  be  a  complete  ad- 
hesion, eventually,  between  the  opposing  surfaces,  as  the  disease  pro- 
gresses. In  some  cases,  and  especially  in  tuberculosis,  we  may  also 
find  an  adhesion  between  the  outer  surface  of  the  pericardium  and 
the  pulmonary  pleura. 

Acute  plastic  or  dry  pericarditis  is  usually  a  secondary  form  of 
the  disease.  It  is  almost  always  due  to  some  antecedent  or  concom- 
itant affection  of  the  lungs  or  heart ;  or  to  some  general  dyscrasia. 

Owing  to  the  constant  friction  of  the  opposing  surfaces  of  the 
pericardium,  the  membrane  is  apt  to  have  a  rough  appearance,  due 
to  the  rubbing  of  the  filaments  of  fibrin  that  extend  across  the  sac. 
When  these  filaments  have  any  length,  they  give  a  "hairy"  or  villous 
look  to  the  membrane ;  hence  the  name  "hairy  heart/'  cor  villosum. 
Sometimes  serum  or  pus  becomes  lodged  in  the  interstices  between 
the  fibres  or  in  the  meshes  of  this  imperfectly  formed  connective 
tissue,  giving  the  whole  a  honeycombed  appearance.  At  first  the 
heart  muscle  will  retain  its  integrity,  but  if  the  attachment  contin- 
ues, the  muscular  tissue  will  begin  to  disintegrate,  at  first  along  the 
border  of  the  pericardium.  In  adherent  pericardium  of  long  stand- 
ing, there  is  invariably  myocardial  degeneration,  a  condition  which 
is,  of  course,  irremediable.  Where  there  has  been  an  attachment  be- 
tween the  visceral  and  parietal  layers  of  the  pericardium  and  they 
become  detached,  the  point  of  separation  is  apt  to  be  marked  by  a 
deposit  of  fibrous  tissue,  the  "milk  patch."  There  are  other  ways, 
however,  in  which  this  patch  or  spot  is  produced. 

Sometimes  there  are  few  or  no  objective  signs.  The  patient 
may,  however,  complain  of  prsecordial  weight  or  distress ;  or  refer  to 
a  pain  in  the  ensiform  cartilage.    The  pain  may  be  steady  or  periodic, 


Pericardial    Diseases  i6i 

slight  or  intense.  It  may  extend  up  the  neck,  or  down  the  icft  arm. 
As  soon  as  effusion  occurs,  there  is  a  diminution  of  the  pain.  It 
may  be  caused  at  first  by  the  friction  of  the  opposing  rough  surfaces. 
Distention  of  the  sac  with  fluid,  however,  wih  cause  a  return  of  the 
pain.  Occasionahy  the  pain  is  anginoid  in  character.  Usually  there 
is  some  fever,  but  the  temperature  seldom  rises  above  102  degrees, 
though  it  may  reach  108  or  more  before  death.  In  a  single  in- 
stance, associated  with  broncho-pneumonia,  I  knew  it  to  reach  no 
at  death.  Ordinarily  the  nervous  symptoms  consist  merely  of  head- 
ache ;  but  there  may  be  melancholia  or  delirium.  Among  other 
phenomena  I  have  noted  dizziness,  faintness  and  even  cyanosis. 

Rheumatic  pericarditis  usually  occurs,  if  at  all,  during  the  first. 
or  second  week  of  inflammatory  rheumatism,  but  it  may  precede  the- 
general   rheumatic   attack. 

The  first  of  the  physical  signs  is  difficult  inspiration,  but  this  sign.' 
may  be  absent.  Palpation  over  the  pericardium,  however,  may  re- 
veal a  fremitus.  If  felt,  it  is  usually  over  the  right  ventricle,  the- 
most  anterior  portion  of  the  heart.  There  may  be  a  thrill.  The- 
heart's  action  is  apt  to  be  irregular,  even  tumultuous.  Auscultationi 
may  reveal  friction  sounds,  the  most  distinctive  of  the  signs.  It  is 
a  double  sound,  not  perfectly  synchronous  with  the  heart,  and  some- 
what more  prolonged.  Yet  these  friction  sounds  may  be  mistaken 
for  endocardial  murmurs  by  experienced  clinicians.  I  have  known 
several  such  cases,  as  the  autopsies  have  shown.  Although  usually 
double,  the  friction  sounds  may  be  single  or  triple.  They  are  in 
every    case    transitory. 

The  sound  may  also  have  a  peculiar  rubbing  or  creaking  sound, 
like  that  of  new  leather,  or  it  may  be  musical.  It  is  always  super- 
ficial, close  to  the  ear,  and  intensified  by  the  pressure  of  the  stetho- 
scope on  the  fourth  and  fifth  interspaces. 

Friction  sounds  may  be  heard  up  and  down  the  sternum.  They 
are  often  best  noted  over  the  aorta,  but  may  be  heard  at  the  apex. 
Unlike  valvular  murmurs,  they  are  not  transmitted  in  definite  direc- 
tions, while  the  intensity  depends  on  the  position  of  the  patient. 
They  are  best  heard  when  he  takes  the  upright  posture.  The  pulse 
may  be  feeble,  rapid,  irregular,  paradoxical  or  dicrotic.  It  may  be 
as  slow  as  56  or  as  rapid  as  130,  in  my  experience. 

Another  symptom  is  the  epigastric  pulse,  but  this  is  not  dis- 
tinctive. It  is  seen  in  Graves'  disease,  and  in  other  nervous  condi- 
tions. 

The  great  difficulty  in  the  diagnosis  of  acute  plastic  pericarditis 


i62  Pericardial  Diseases 

is  that  it  is  apt  to  be  obscured  by  attendant  pulmonary  or  cardiac 
diseases,  which  may  completely  mask  or  overshadow  characteristic 
symptoms. 

The  course  of  an  attack  of  acute  pcricartHtis  will  vary.  It  may 
last  only  a  few,  days  ;  or  it  may  take  on  the  sub-acute  form,  passing 
into  pericarditis  with  ettusion. 

On  the  whole,  the  friclion  sdUiuls  of  pericarditis  are  not  ditiicult 
to  recognize,  and  should  not  be  mistaken  for  organic  valvular  mur- 
murs ;  though,  as  mentioned,  this  mistake  has  sometimes  been  made 
bv  ouv  most  lu'ominent  clinicians.  It  is  more  difficult  sometimes 
to  distinguish  between  pericardial  and  pleuritic  frictiou  sounds. 
This  danger,  however,  can  be  eliminated  by  making  the  ])atient  take 
a  deep  inspiration  and  then  hold  his  breath.  \W  this  act  the  lungs, 
if  not  attached  l)y  adhesions,  will  be  retracted  widely  apart,  leaving 
the  pericardium  quite  uncovered  by  pulmonary  tissue. 

Pericarditis  rarely  kills  directly.  It  is  the  secondary  effects  of 
it,  that  are  to  be  feared.  The  fibrine  may  be  absorbed,  and  that 
is  the  end  of  it,  so  far  as  danger  to  the  integrity  of  the  heart  is 
concerned  ;  or  it  may  survive  as  a  scar  on  the  heart's  surface,  known 
as  the  "milk  patch."  But  if,  as  the  inflammation  subsides,  the  two 
opposing  pericardial  surfaces  unite  or  cohere,  the  result  will  neces- 
sarily be  hypertrophy  and  dilatation  of  the  heart,  and  degeneration 
of  its  substance. 

In  tubercular  pericarditis  there  is  great  thickening  of  both  the 
parietal  and  visceral  layers  of  the  pericardium,  and  the  acute  dis- 
ease always  goes  on  to  the  chronic  form.  Eventually  there  is  more  or 
less  a  completely  adherent  pericardium. 

The  treatment  of  acute  dry  pericarditis  is  simple.  The  patient 
should  be  put  at  rest.  Sedatives,  such  as  the  bromides,  serve  a  use- 
ful purpose.  Rubefacients,  blisters  and  dry  cups  are  also  indicated. 
More  than  these  are  rarely  necessary. 

Pericarditis  ivith  effusion  presents  special  features.  It  is  usu- 
ally the  sequel  to  the  acute  form  just  described.  The  effusion  may 
be  serous,  bloody  or  purulent,  and  the  amount  will  vary  from  i  to 
70  or  more  ounces.  In  my  experience  it  is  usually  from  8  to  15 
ounces.  This  form  of  pericarditis  is  common  in  pleurisy,  pneu- 
monia, endocarditis  and  acute  rheumatism.  Although,  as  I  have 
said,  it  is  apt  to  be  a  sequel  to  the  acute  form  just  described,  the 
onset  may  not  be  appreciated,  owing  to  its  insidious  character ;  but 
there  may  be  pain,  which  is  usually  increased  by  pressure.  Dyspnoea 
and  palpitation  are  also  symptoms,  when  the  effusion  is  extensive. 


Pericardial  Diseases  163 

In  such  instances  the  patient  will  show  signs  of  restlessness,  or  his 
countenance  will  be  anxious.  The  pulse  may  become  rapid — it  may 
reach  even  to  200,  300  or  400,  and  be  paradoxical ;  it  may  be  very 
weak  or  disappear  on  inspiration.  There  may  be  distention  of  the 
veins  of  the  neck.  In  rheumatic  forms  it  is  not  unusual  to  have 
cerebral  symptoms ;  indeed,  there  may  be  delirium  and  coma,  but 
these  will  be  due  to  the  intercurrent  disease. 

With  ordinary  cases  of  moderate  effusion,  in  adults,  there  will  be 
no  external  manifestation  of  the  effusion ;  but  in  children,  if  the  effu- 
sion is  large,  there  is  bulging  of  the  prcucordial  region;  and,  per- 
haps, coincidentally,  oedema  of  the  chest- wall.  On  palpation  the 
apex  beat  may  not  be  found.  If  a  friction  sound  has  been  heard, 
it  will  usually  disappear  as  the  effusion  extends ;  or  it  will  re- 
main for  a  while,  exclusively  at  the  base.  On  percussion  there  will 
be  an  area  of  increased  dulness  about  the  base  of  the  heart.  The 
shape  of  this  area  is  peculiar.  Unlike  the  area  of  cardiac  dulness, 
the  outline  will  be  that  of  a  pear  or  truncated  cone,  with  the  base  be- 
low the  sixth  rib  and  the  apex  at  or  above  the  second  interspace.  I 
have  know,  in  an  exceptional  instance,  the  transverse  width  of  the 
pericardial  effusion  to  be  eight  inches,  and  reach  from  nipple  to 
nipple.  As  the  effusion  increases,  the  heart  sounds  become  more 
indistinct.  Whenever  the  pericardial  friction  sound  is  distinctly 
heard,  the  physician  should  anticipate  a  possible  effusion,  and  at 
once  demarcate  the  heart's  area  with  a  dermographic  pencil,  so  that 
any  increase  in  the  area  will  be  shown,  and  he  may  thus  be  able  to 
note  the  progress  of  the  effusion. 

The  effusion  may  extend  rapidly,  causing  suffocative  symptoms, 
or  may  subside  very  rapidly.  Even  exudations  of  pus,  if  small,  may 
sometimes  be  absorbed.  Such  septic  cases,  however,  sometimes 
terminate  fatally,  in  a  few  hours.  On  the  other  hand,  large  serous 
effusions  developing  slowly  may  be  borne  fairly  well  for  several 
weeks,  giving  ample  time  to  institute  remedial  measures. 

In  general,  serous  effusions  disappear  of  themselves  without 
special  treatment  directed  to  the  effusion.  In  the  purulent  or  hsemor- 
rhagic  forms,  of  which  I  will  speak  later,  the  disease  is  usually  fatal, 
because  the  constitutional  and  concomitant  diseases,  which  are  the 
more  serious,  are  of  a  fatal  character.  In  rheumatic  cases  the  prog- 
nosis is  apt  to  be  favorable.  In  other  cases  of  serous  effusion  the 
prognosis  is  more  uncertain. 

It  is  not  always  easy  to  distinguish  between  dilatation  of  the  heart 
and  pericardial  effusion,  especially  in  stout  people  and  in  women 


164  Pericardial  Diseases 

whose  breasts  are  large.  In  dilatation,  from  whatever  eause,  there 
is  a  waving  impulse  of  the  heart,  and  the  apex  is  better  felt  gen- 
erally ;  though  in  many  cases  of  fatty  heart  it  may  not  be  appreciable. 
A  point  of  great  importance,  however,  is  the  configuration  of  the 
dull  area.  A  skillful  percussor  can  in  most  cases  outline  the  heart's 
borders  sufficiently  well  to  show  the  general  contour.  In  enTarge- 
ment,  the  heart  is  shaped  like  a  pear,  with  the  small  end  directed 
downward  and  outward  :  while  in  eflfusion.  when  there  are  eight 
ounces  or  more,  the  form  of  the  sac,  as  marked  out  on  the  chest  wall, 
will  be  pear-shaped,  with  the  base  directed  downward  ond  out- 
ward, and  the  small  end  directed  toward  the  manubrium.  Change 
of  position  in  the  patient  makes  very  little  difiference  in  the  area 
of  dulness  in  enlarged  hearts,  while  in  pericardial  effusions  a  consid- 
erable difference  is  generally  apparent.  If  physicians  would  prac- 
tice demarcation  of  the  heart  by  percussion,  it  is  probable  that  they 
would  learn  to  avoid  the  mistake  that  is  sometimes  made  of  con- 
founding hydro-pericardium  with  a  large  heart.  The  greatest  diffi- 
culty is  often  found  in  distinguishing  a  pericardial  from  a  pleuritic 
effusion.  We  should  remember,  however,  that  a  large  pericardial 
effusion  will  compress  the  lung,  much  as  a  pleural  effusion.  In 
both,  the  lungs  will  be  compressed  if  there  is  much  fluid,  but  in  peri- 
cardial effusions  compression  will  be  mainly  exerted  on  the  lower 
lobe  of  the  left  lung,  forcing  it  towards  the  left,  and  if  this  lobe  is 
much  compressed  there  should  be  increased  vocal  resonance  and 
bronchial  breathing,  heard  from  behind. 

Both  in  pericardial  and  pleural  effusions  the  respiratory  sounds 
are  feeble  whenever  the  action  of  respiration  is  interfered  with.  It 
is  well  to  remember  that  in  rheumatism  the  effusion  is  apt  to  be  sero- 
fibrinous ;  in  tuberculosis  it  may  be  fibrinous  or  fibro-purulent ;  in  in- 
fective diseases,  such  as  malignant  endocarditis,  it  will  probably  be 
more  or  less  haemorrhagic.  In  the  effusions  of  old  people  there 
is  also  a  tendency  to  the  haemorrhagic  form.  Some  curious  mis- 
takes are  shown  by  my  hospital  records.  Thus,  I  have  known  en- 
largement of  the  left  lobe  of  the  liver  to  be  mistaken  for  pericarditis 
with  effusion.  So  small  an  amount  of  liquid  as  4  to  6  oz.  will  not 
ordinarily  be  detected,  and  yet  it  may  be  assumed  that  if  effusion 
takes  place  in  a  case  of  acute  heart  disease,  the  amount  of  liquid  in 
the  sac  will  be  at  least  from  4  to  8  oz.  Unless  we  resort  to  aspiration, 
however,  there  is  no  way  of  distinguishing  between  pericarditis  with 
a  serous  effusion  and  hydro-pericardium,  due  to  dropsy  of  the  sac. 

In  the  matter  of  treatment,  absolute  rest  in  bed  is  the  first  indi- 


Pericardial  Diseases  165 

cation.  In  extreme  cases,  wet  cups  to  the  prjecordium  may  be  ad- 
visable for  plethoric  people,  but  my  experience  tells  me  that  they 
should  seldom  be  resorted  to  in  any  instance.  Dry  cups  and  rubefa- 
cients are  in  order,  however.  The  ice  or  cold-water  bag  are  recom- 
mended by  continental  physicians,  but  at  best  they  should  only  be 
used  for  temporary  relief.  The  diet  should  be  carefully  regulated,  so 
as  to  prevent  gaseous  distention  of  the  stomach,  which  adds  greatly 
to  the  pericardial  distress.  The  physician  should  address  himself 
promptly  to  the.  kidneys  and  skin,  in  order  to  relieve  the  system 
of  its  superfluous  fluids,  and  also  to  the  heart  itself ;  and  digitalis, 
which  is  both  an  established  heart  stimulant  and  diuretic,  will  here 
hold  the  first  rank.  It  should  be  given  in  doses  of  i  to  2  grains  of 
the  substance  two  or  three  times  a  day,  or  by  tincture  or  infusion. 
Acetate  of  potash  has  achieved  an  excellent  reputation  in  cardiac 
effusions.  It  is  both  a  diuretic  and  a  diaphoretic.  From  10  to  30 
grains  may  be  given  every  four  hours.  In  the  smaller  dose  it  is  a 
diaphoretic.  A  common  remedy  is  the  pill  of  calomel,  digitalis  and 
squill,  one  grain  each,  to  be  taken  three  times  a  day.  An  excellent 
remedy  is  Basham's  mixture,  consisting  of  the  chloride  of  iron,  dilute 
acetic  acid  and  the  acetate  of  ammonia.  It  is  both  a  diuretic  and  dia- 
phoretic, and  never  produces  alarming  symptoms.  If  the  disease 
has  taken  on  a  sub-acute  form,  iodide  of  potassium,  in  7  to  10  grain 
doses  three  times  a  day,  will  tend  to  absorb  the  fluid.  It  will 
sometimes  act  very  efficiently,  though  slowly,  in  very  large  serous 
effusions.  Ordinarily  alcoholics,  and  perhaps  diffusible  stimulants, 
or  heart  tonics,  like  strychnine,  in  doses  of  from  1-60  to  1-25  grains, 
may  be  found  desirable.  In  great  praecordial  pain  and  distress 
opium  may  be  necessary ;  or  trional,  in  doses  of  from  15  to  30  grains. 
Paracentesis  may  be  applicable  in  some  cases.  In  sixty  cases  col- 
lected by  Roberts  there  were  twenty-one  recoveries  after  the  opera- 
tion. There  are  different  views  as  to  the  proper  site  for  the  punc- 
ture. Some  recommend  introduction  of  the  aspirator  needle  in  the 
fourth  or  fifth  interspace,  2  to  2^  inches  from  the  left  edge  of  the 
sternum  (MacDonnell).  Roberts  insists  that  the  best  spot  is  the 
fifth  left  interspace,  2  to  2^4  inches  from  the  median  line  of  the 
sternum.  Bristowe  says  the  preferable  site  is  at  the  inner  end  of  the 
fourth  or  fifth  left  interspace,  close  to  the  sternum.  He  suggests 
the  use  of  a  fine  aspirating  needle,  first,  to  determine  the  character  of 
the  liquid.  Rotch  recommends  the  fifth  space,  to  the  right  of  the 
sternum.  Others  advise  the  third  left  space,  i^  inches  from  the 
sternum.      The  important  point  is  not  to  injure  the  internal  mam- 


i66  Pericardial  Diseases 

mary  artery,  uliicli  runs  along  the  edge  of  the  sternum  until  it 
reaches  the  sixth  ril),  where  it  bifurcates,  continuing  downward  and 
outward  in  tlie  sixth  interspace.  The  operation  should  be  done 
slowly  and  careful! \.  Jt  is  not  demanded  except  in  rare  cases.  Ac- 
cording to  MacDonnell.  the  normal  pericardium  can  only  me  made 
to  contain,  under  jiressure.  about  lo  oz.  of  liquid,  but  according  to 
Stokes.  36  oz.  nia\  not  produce  dysphagia,  and  yet  a  sudden  dis- 
charge of  a  few  ounces  of  blood  or  stomach  contents  into  the  sac 
may  cause  sudden  death.  Sometimes  there  may  be  pus  in  the  peri- 
cardium, either  by  itself  or  intermixed  with  the  serum  and  fibrine  or* 
blood.  It  is  always  secondary,  and  due  to  some  deposit  of  pus  else- 
where, as,  for  example,  from  an  abscess  of  the  liver,  pyaemia,  or 
septic  peritonitis.  In  fact,  if  any  accunuilation  takes  place  in  the  peri- 
cardial sac  in  the  course  of  these  affections,  is  is  jjretty  apt  to  become 
purulent.  The  remedy  for  such  a  condition  is  incision,  free  drain- 
age, and  antisei)tic  injections.  It  is  hartlly  worth  while  to  expect 
that  a  cure  will  follow  aspiration,  even  if  it  is  frequently  repeated. 
Some  little  success  has  attended  the  operation  by  thorough  drain- 
age. \\hile  a  very  small  amount  of  pus  in  the  pericardium  may  be 
absorbed  or  calcified,  a  large  amount  will  inevitably  lead  to  a  fatal 
issue,  unless  free  incision  be  resorted  to.  When  blood  is  effused 
in  the  pericardium,  it  is  the  result  of  injury  to  the  pericardium,  heart 
or  great  vessels,  or  it  may  be  the  result  of  disease  in  some  adjacent 
part,  such  as  pneumonia.  It  is  apt  to  be  associated  with  aneurism 
of  the  first  part  of  the  aorta.  The  only  way  of  detei'mining  whether 
blood  is  present  or  not,  is  by  aspiration.  The  amount  is  usually  small. 
Large  or  sudden  hemorrhages  may  cause  the  heart  to  stop  sud- 
denly. While  this  kind  of  effusion  has  in  some  instances  been  re- 
lieved by  aspiration,  the  accumulation  is  so  rapid  and  unexpected 
that  the  ]Datient  ma\-  be  dead,  before  his  malady  is  even  suspected. 

The  pericardium  usuall\-  holds  from  half  an  ounce  to  an  ounce 
of  a  greenish-yellow  serum.  When  a  considerable  quantity  is  pres- 
ent in  dro])sy  cases,  we  have  hydro- pericardium,  or  pericardial 
dropsy.  This  may  be  borne  satisfactorily,  if  the  effusion  is  not  too 
rapid.  In  the  following  case  of  acute  hydro-pericardium  it  appears 
to  have  caused  death,  though  the  fluid  was  only  eight  ounces  in 
amount. 

'^Case  L.  Acute  hydro-pcricardiiun:  Meningitis. — L.,  30.  Ire- 
land, was  admitted  to  hospital  Sept.  23,  1881.  He  had  been  made 
to  walk  to  the  st;ation-house  under  the  supposition  that  he  was  in- 
toxicated.     He  was  then  taken  to  the  hospital  in  an  ambulance.     On 


Pericardial  Diseases  167 

admission  he  was  found  to  he  morihund.  Pulse  almost  impercepti- 
hle.  i-ieart  sounds  indistinguishahle.  Apex  heat  faintly  felt,  one- 
half  inch  to  the  left  of  the  nipple.  Cardiac  dulness  increased.  Urine 
negative.  He  was  temporarily  revived,  hut  died  suddenly  on  the 
same  day,  after  makinj^  a  slight  exertion.  At  the  post-mortem  ex- 
amination the  pericardium  was  found  to  contain  eight  ounces  of  a 
clear  serum  ;  but  there  were  numerous  ecchymotic  spots  beneath  the 
visceral  and  parietal  layers  of  the  pericardium,  especially  over  the 
roots  of  the  great  vessels.  There  was  also  a  small  extravasation  of 
blood  in  the  cardiac  muscle  near  the  apex,  just  beneath  the  visceral 
pericardium.  On  the  heart  were  a  number  of  milk  patches,  and 
some  thick  fibroid  deposits  of  comparatively  recent  date,  with  fibrous 
bands  stretched  across  the  upper  part  of  the  pericardial  sac.  The 
heart  was  hypertrophied  and  weighed  24  ounces.  Its  cavities  also 
were  all  dilated.  Some  tricuspid  insufficiency  (relative),  but  other- 
wise no  valvular  disease.  Muscular  substance  pale,  soft  and  flabby. 
Liver  enlarged  and  congested.  Serous  effusion  within  calvarium 
and  spinal  canal.      Meninges  of  brain  thick  and  opaque. 

The  sudden  death  was  attributed,  and  correctly,  I  think,  to  the 
acute  hydro-pericardium. 

The  following  is  a  case  of  acute  fibrinous  pericarditis,  or  "Hairy 
Heart": 

Case  LI.  Acute  Articular  Rheumatism:  Acute  Pericarditis: 
Hairy  Heart. — M.,  39,  was  admitted  to  hospital  Nov.  19,  1883,  suf- 
fering from  acute  inflammatory  rheumatism.  Heart's  action  irreg- 
ular. About  the  i8th  day  double  friction  sounds  were  heard  over  the 
pericardial  region,  and  continued  for  three  days.  Notwithstanding 
active  treatment  by  means  of  the  salicylates,  digitalis,  and  external 
applications,  including  blisters  to  the  pericardium,  acute  delirium 
supervened,  and  he  died  on  the  nth  day  after  admission,  in  semi- 
coma. At  the  post-mortem  examination  the  pericardial  sac  was 
found  to  contain  15  ounces  of  clear  serum.  Both  visceral  and  pari- 
etal layers  of  the  pericardium  were  covered  with  the  papillarv 
growths  characteristic  of  the  "Hairy  Heart."  At  the  apex  the  two 
pericardial  surfaces  w^ere  connected  by  a  few  bands. 

The  following  is  a  case  of  acute  purulent  pericarditis : 

Case  LU.  Lobar  Pneumonia:  Endocarditis:  Pvo-Pericardium: 
Pleurisy  zvifh  Effusion. — R..  21,  male,  was  admitted  to  hospital  Feb. 
15,  1877,  suffering  from  lobar  pneumonia.  Pulse  92,  temperature 
101°  F.  The  patient  did  well  for  five  days,  but  on  the  20th  the 
temperature  and  pulse  rose,  the  former  to  105°  F.,  the  latter  to.  130. 


l68  Pericardial  Diseases 

On  the  following  day  ho  was  delirious,  and  died,  suddenly,  in  the 
evening-.  At  the  post-mortem  examination  was  found  some  ad- 
hesive inflammation  of  the  pericardium,  which  contained  two  ounces 
■of  pus.  Heart  dilated  and  hypertrophied.  Myocardial  degenera- 
tion. \'egetations  on  the  aortic  valves.  Liver  large  and  con- 
gested. Pneumonia  in  the  stage  of  resolution.  Pleurisy  with  ef- 
fusion. The  precise  cause  of  the  sudden  death  was  not  apparent. 
It  was  probably  due  to  the  pneumonia. 

The  following  is  a  case  of  chronic  tibrinous  pericarditis  (adhcr- 
•ent  pericardium),  showing  how  it  may  pass  unnoticed,  even  under 
the  eve  of  an  experienced  clinician : 

Case  LIU.  Lobar  Pneumonia:  Adherent  Perieardium. — C,  36, 
was  admitted  to  hospital  March  21,  1888,  after  exposure  to  cold  and 
wet.  A  few  days  previously  he  had  a  chill,  with  pain  in  his  side, 
and  on  the  next  day  cough  and  a  brownish  expectoration,  with  some 
dyspnoea.  On  examination  he  was  found  to  have  pneumonia. 
Heart's  action  feeble.  Temperature,  1043/2°  F.  Albumin  in  urine, 
5  per  cent.  During  the  few  da}s  he  was  in  the  hospital  his  heart 
■never  acquired  an}-  additional  force.  He  died  of  heart  failure.  At 
the  post-mortem  examination  the  pericardial  sac  was  found  to  be 
completelv  obliterated  by  old  adhesive  inflammation.  Cardiac  hy- 
pertroi)hy  and  dilatation.  Red  hepatization  of  left  lung.  Some 
pleurisy  with  effusion  on  both  sides.  Enlarged  spleen ;  hob-nailed 
liver  ;  chronic  nephritis.  The  adherent  pericardium  was  only  one 
of  the  contributing  causes  of  death  which  was  due  primarily  to  pneu- 
monia and  uremia. 

PIvdro-perocardium  occurs  frequently  in  chronic  Bright's  disease, 
and  sometimes  in  scarlet  fever.  The  diagnosis  is  a  matter  of  infer- 
ence, unless  aspiration  is  resorted  to ;  but  the  clinical  history  of  the 
case  will  generally  suggest  the  character  of  the  effusion.  Its  treat- 
ment has  been  considered  under  that  of  pericarditis  with  effusion. 

Pneumo-cardium,  or  air  in  the  sac,  is  of  very  rare  occurrence.  The 
causes  are.  as  far  as  we  know,  cancer,  ulcer  of  the  stomach,  and  per- 
foration, as  from  wounds.  If  there  is  a  large  collection  of  gas,  the 
action  of  the  heart  is  naturally  interfered  with,  causing  dyspnoea, 
cyanosis  and  collapse.  The  ordinary  area  of  dulness  is  replaced  by 
areas  of  metallic,  or  cracked-pot  sounds,  over  the  gas.  Splashing 
mav  possibly  be  heard.  The  sounds  are  like  those  of  a  circum- 
scribed pneumo-thorax,  but  we  may  distinguish  the  two  in  this  way: 
When  respiration  is  suspended  the  sounds  persist.  Recovery  has 
taken  place  in  a  few  rare  instances.      The  treatment  is  surgical.     In 


Pericardial  Diseases  169 

chronic  pericarditis,  or  the  adherent  pericardium  (for  this  is  the 
only  form  that  can  persist  and  be  compatible  with  lifej,  the  attach- 
ment may  be  partial  or  general,  as  I  have  already  said.  Slight  at- 
tachments, especially  over  the  great  vessels,  are  common  and  have 
no  great  significance.  Occasionally  a  fibrous  band  or  two  persist 
after  an  attack  of  acute  pericarditis,  but  they  will  not  excite  atten- 
tion unless  the  heart's  action  is  interfered  with.  When  there  is 
such  a  general  adhesion  that  the  heart  and  pericardium  are  prac- 
tically united,  the  consequences  are  always  serious.  Several  things 
happen.  At  first  the  heart  enlarges  to  overcome  the  embarrassing 
efTect  of  its  attachment  to  the  pericardium  ;  then  it  dilates,  and  later 
undergoes  more  or  less  true  fatty  degeneration.  Obliteration  of  the 
pericardial  sac,  which  is  not  uncommon,  especially  in  old  rheumatic 
cases,  is  necessarily  followed  by  degenerative  changes  in  the  myo- 
cardium. There  are  no  distinctive  signs,  but  merely  those  of  ad- 
vanced heart  disease,  such  as  dyspnoea,  palpitation,  a  sense  of  prse- 
cordial  constriction,  cyanosis  and,  perhaps,  dropsy.  In  these  cases 
we  find  an  enlarged  area  of  cardiac  dulness,  with  an  enlarged  area 
of  cardiac  impulse,  which  may  extend  from  the  third  to  the  sixth 
interspace.  There  is  no  characteristic  wave  of  the  impulse  in  ad- 
herent pericardium,  but  retraction  of  the  apex  during  systolic  is  an 
important  sign.  .  Friedreich's  sign  is  also  to  be  mentioned.  It  is 
collapse  of  the  veins  of  the  neck  during  cardiac  diastole.  It  is 
noticeable  in  adherent  pericardium,  that  the  dulness  on  percussion 
may  reach  the  first  interspace.  On  auscultation,  the  pulse  may  have 
a  galloping  rhythm,  or  may  be  paradoxical. 

In  my  experience,  however,  as  derived  from  a  study  of  my  hos- 
pital cases,  adherent  pericardium  is  seldom^  recognized  during  life ; 
and  my  cases  have  passed  under  the  observation  of  our  best  clin- 
icians. Assistance  in  diagnosis  may  be  derived  from  the  fact  that 
two-thirds  of  these  cases  have  been  associated  with  acute  articular 
rheumatism.  Pleurisy  and  tuberculosis  are  also  manifest  causes. 
In  many  of  my  cases  there  was  dyspnoea  and  prgecordial  pain ;  the 
"heart's  action  was  weak,  and  the  sounds  were  muffled.  Other  signs 
that  I  have  noted  in  adherent  pericardium  were  cough  and  an  infre- 
quent pulse.  A  soft  systolic  bruit  at  the  apex  was  not  uncommon. 
Sometimes  creaking  sounds  were  heard  over  the  pericardium,  as  if 
old  adhesions  were  being  stretched. 


^  In  fact,  in  the  many  cases  I  have  seen  at  post-mortems.  I  do  not  remem- 
ber that  the  diagnosis  was  made  in  a  single  instance. 


Chapter  XV. 
FUNCTIONAL   CARDIAC    DISEASES. 

I'ALl'lTATION  ;   ABNORMAL    RHYTHM;^    THE    FREQUENT    rULSK." 

Some  peculiar  cardiac  phenomena  are  conveniently  grouped  un- 
der the  titles  of  Palpitation.  Abnormal  Rhythm,  the  Frequent  and 
Infrequent  Pulse,  and  Graves's  Disease.  They  are  also  sometimes 
classed  under  the  Cardiac  Neuroses — which  indicates  the  paramount 
implication  of  the  nervous  system  in  their  production,  without  ne- 
cessitating the  adoption  of  any  set  theories  as  to  the  source  or  modus 
operandi  of  the  nerve  influences.  Three  of  these  neuroses  will  be 
here  described. 

Palpifafio)!  is  the  most  common  of  them.  It  is  a  subjective  phe- 
nomenon, a  beating  of  the  heart  felt  by  the  patient  as  a  disagreeable 
or  oppressive  sensation,  although  the  pulse  is  not  necessarily  in- 
creased in  frequency.  These  characteristics  distinguish  it  sharply 
from  the  frequent  })ulse  of  so-called  tachycardia,  which  is  not  neces- 
sarily appreciated  by  the  patient. 

The  cause  of  palpitation  is  not  always  apparent.  It  may  be  due 
to  disease  of  the  heart  substance,  as  m  the  cardiac  hypertrophy  of 
Bright's  disease ;  or  to  functional  disturbance  of  the  cardiac  nerves, 
as  in  neurasthenia  ;  or  to  some  defect  in  the  quality  or  quantity  of  the 
blood,  as  in  anaemia. 

In  general,  we  recognize  three  kinds  of  causes :  the  direct,  the 
reflex,  and  the  toxic.  The  direct  are  subdivided  into  the  or<^anic 
and  the  functional.  For  example,  in  diseases  of  the  spinal  cord  in- 
volving the  roots  of  the  pneumogastric  ;  and  in  pressure  on  or  dis- 
ease of  this  nerve,  the  cause  is  direct  and  organic,  and  many 
examples  of  this  variety  liave  been  observed.  On  the  contrary,  in 
the  i)alpitations  of  the  emotions,  such  as  are  due  to  sudden  alarm, 
distress,  apprehension,  or  even  pleasurable  sensations,  the  cause  is 
direct  and  functional.  Palpitations  of  this  kind  are  common  enough 
in  every  one's  experience.  Reflex  palpitations  also  are  many  and 
various.  Most  noteworthy  of  all.  perhaps,  are  those  produced  by 
gastro-intestinal   intoxications,   the  result   of  absorption   of  certain 


Allorhythmia.  arrhythmnia. 

Originally  published  in  Intcnwt.  Clinics,  Vol.  4.  Ser.  13,  p.  83. 


Functional  Cardiac  Diseases  171 

toxins  into  the  system.  On  the  other  hand,  distention  of  these  or- 
gans, the  result  of  disordered  functions,  may  cause  pressure  on  the 
heart  or  large  venous  trunks,  mechanically  disturbing  the  heart's 
action  and  causing  palpitation ;  or  venous  congestion  due  to  the 
various  sorts  of  enteroptoses  may  bring  on  a  seizure.  Diseases  of 
the  kidneys,  gall-bladder,  ovaries,  or  uterus  are  also  reflex  causes, 
and  the  cessation  of  palpitation,  when  affections  of  these  offending 
organs  have  been  successfully  treated,  offers  a  priori  evidence  in 
favor  of  this  view. 

A  special  toxic  agent  is  alcohol,  and  tobacco  is  prominent  in  this 
relation  to  a  marked  degree,  so  much  so  that  the  term  "tobacco 
heart"  is  well  known  and  in  general  use.  Coffee  and  tea,  to  a  less 
degree,  produce  palpitation.  In  fact,  palpitation  is  usually  the  re- 
sult of  nervous  influences,  rather  than  organic  heart  disease. 

Palpitation  implies  an  irregular  and  sometimes  tumultuous  ac- 
tion of  the  heart.  If  slight,  it  may  only  cause  a  mild  discomfort, 
but  the  impulse  can  be  so  violent  as  to  shake  the  whole  body.  While 
in  healthy  persons  nothing  short  of  a  sudden  alarm  of  fire,  the  shock 
of  a  railway  accident,  etc.,  will  bring  on  an  attack,  in  neurotic  indi- 
viduals circumstances  of  an  apparently  trivial  nature,  such  as  a 
discordant  voice,  a  ring  at  the  bell,  or  mere  apprehension  that  an 
accident  or  misfortune  is  impending,  are  sufficient.  Under  these 
circumstances  the  heart  may  seem  to  actually  stand  still. 

But  palpitation  is  not  a  disease.  It  is  merely  one  of  many  phe- 
nomena, such  as  a  feeling  of  constriction  in  the  throat,  embarrassed 
respiration,  pallor  or  flushing  of  the  face,  prsecordial  oppression, 
perhaps  cerebral  congestion,  which  are  frequently  associated  to- 
gether. Lassitude  and  exhaustion  are  the  sequels  of  severe  attacks. 
Women,  having  a  feebler  nervous  temperament,  are  more  subject 
to  it  than  men.  The  pulse  may  run  up  to  150,  or  more,  a  minute. 
When  seizures  are  induced  by  gastro-intestinal  intoxications  they 
are  attended  by  dyspeptic  symptoms,  often  with  distention  and  eruc- 
tation of  gas. 

So  far  as  the  heart  is  concerned,  no  change  will  take  place  in  it. 
provided  the  attacks  are  mild  and  infrequent.  If  severe  or  pro- 
longed, however,  the  organ  becomes  dilated.  But  palpitation  of 
itself  does  not  produce  murmurs. 

In  the  treatment  it  is,  of  course,  essential  to  recognize  the  cause. 
If  the  palpitation  is  due  to  Bright's  disease,  remedies  that  tend  to 
improve  the  condition  of  the  kidneys  are  indicated — such  as  iron 


1/2  Functional  Cardiac  Diseases 

and   spirit  of  Mindererus.   which  are   well   combined  in   Basham's 
mixture,  as  follows : 

Ijt     Tincture  of  iron  chlorid 3      drams 

Dilute  acetic  acid 2      drams 

Simple  syrup i\A  ounces 

Solution  of  cimnioniuni  acetate,  sufficient  to  make  4      ounces 

Alix.     S. — One  teaspoonful   4  times  a   day. 

Excesses  of  all  kinds  must  be  abstained  from.  Over-eating  and 
over-drinking;  are  to  be  remedied  by  regulating  the  diet  and  giving 
saline  laxatives,  especially  those  containing  sodium  phosphate.  Or- 
dinary constipation  is  successfully  combatted  by  stomachics,  or  by 
the  use  of  dilute  nitro-muriatic  acid  combined  with  a  bitter  tonic, 
such  as  gentian.  Either  of  the  following  formulas  will  be  found 
serviceable : 

5c     Bismuth   subgallate  2  grains 

Powdered  cubebs    i/^  grain 

Lactopeptin    i  grain 

Sodium  bicarbonate   i  grain 

Mix.     S. — One  powder  to  be  taken  after  each  meal. 

5     Sodium  bicarbonate  I  dram 

Powdered  rhubarb  yi  dram 

Peppermint  water   2  drams 

Distilled  water,  sufficient  to  make 4  ounces 

Mix.     S. — Two  teaspoonfuls  every  4  hours. 

During  an  attack  the  patient  should  be  made  to  lean  back  in  a 
chair  or  recline  on  a  lounge  or  bed ;  cold  applications  should  be  made 
to  the  chest,  and  as  much  fresh  air  as  possible  should  be  given.  Aro- 
matic spirits  of  ammonia  in  15-  to  25-drop  doses,  in  half  a  glassful 
of  water,  or  Hoffman's  ether,  in  half-dram  doses,  are  also  excellent. 
In  prolonged  cases  the  bromides  are  useful.  Better  than  potassium 
or  sodium  bromides  are  the  mixed  bromidqs.  A  combination  of 
lithium  bromide  5  grains,  ammonium  bromide  10  grains,  and  potas- 
sium bromide  20  grains,  is  more  sedative  than  any  potassium  or 
sodium  salt  singly. 

In  exceptionally  severe  cases  morphine  in  one-quarter  grain  doses 
may  be  necessary.  Electricity,  while  capable  of  doing  good  if  cur- 
rents of  moderate  strength  are  used,  and  for  a  few  minutes  only — 
the  positive  pole  to  the  pneumogastric  of  the  neck  and  the  negative 
pole  over  the  sternum — may  be  dangerous  and  should  be  used  as  a 
last  resort.  The  advantages  are  more  than  offset  by  the  disad- 
vantages, for  a  strong  current  may  stop  the  heart's  action  entirely. 
A  simple  and  effectual  remedy  is  counter-irritation  to  the  chest. 
If  the  palpitation  is  due  to  valvular  disease,  the  treatment  recom- 


Functional  Cardiac  Diseases  173 

mended  for  the  several  forms  of  this  disease  is  applicable.  If  it 
can  be  positively  determined  that  the  palpitation  is  due  to  reflex 
influences,  as  from  a  diseased  ovary,  a  floating  kidney,  etc.,  ap- 
propriate treatment  of  these  organs  is  essential.  After  the  seizure 
has  passed,  it  may  be  necessary  to  enjoin  absolute  rest ;  but  in  some 
cases  tincture  of  strophanthus  or  of  digitalis,  in  3-  to  5-minim 
doses,  may  be  given  until  the  normal  action  of  the  heart  has  been 
restored.  Usually,  however,  a  simple  sedative  or  cardiac  stimulant 
like  camphor  monobromate  in  i-  to  2-grain  doses  will  be  safer  and 
quite  as  effective.  A  good  example  of  palpitation  in  organic  heart 
disease  is  given  in  Case  LIV. 

ABNORMAL    RHYTHM. 

Sometimes  the  normal  rhythm  of  the  heart  is  lost.  This  may  be 
due  to  many  causes,  such  as  mental  or  neurotic  disturbances,  organic 
heart  disease,  reflex  influences  (such  as  from  injuries  to  distant 
parts),  or  toxic  agencies  (such  as  ursemia,)  etc.  Two  or  more  of 
these  may  co-exist.  There  are  several  varieties,  such  as  the  para- 
doxic pulse  of  Kussmaul,  which  is  less  full  during  inspiration,  some- 
times stopping  at  the  end  of  a  long  inspiration.  It  has  been  noted 
in  fibrous  pericarditis,  diseases  of  the  mediastinum,  and  obstruction 
of  the  air-passages.  Other  varieties  have  been  described  in  a  prev- 
ious chapter. 

THE   FREQUENT   PULSE. 

The  frequent  pulse,  like  palpitation,  is  not  a  disease,  but  a  symp- 
tom. It  may  be  physiological  or  pathological.  If  merely  the  accom- 
paniment to  or  sequel  of  violent  exertion,  in  which  the  heart  is 
called  on  for  increased  energy,  within  normal  bounds,  the  frequent 
pulse  is  physiological.  But  from  whatever  cause,  so  far  as  we  know 
at  present,  increased  frequency  must  be  laid  to  nervous  influences. 

Experiments  on  animals  show  that  irritation  of  the  accelerator 
nerves  increases  the  pulse-rate.  Similarly,  section  of  the  pneu- 
mogastric,  or  injury  to  its  nucleus,  increases  the  pulse-rate  to  150 
a  minute  or  over.  It  produces  the  continuously  frequent  pulse.  On 
the  other  hand,  pressure  on  the  pneumogastric  will,  in  some  persons, 
arrest  a  frequent  pulse.  Curiously,  according  to  Martius's  experi- 
ments, when  an  injury  to  the  pneumogastric  causes  a  frequent  pulse, 
the  rhythm  is  always  normal  unless  affected  by  reflex  influences. 
However,  according  to  the  recent  experience  of  Hoffman,  in  cases 
of  paroxysmally  frequent  pulse  with  abrupt  onset,  sudden  ending. 


174  Functional  Cardiac  Diseases 

and  arrhythmia,  the  cause  may  be  the  interpolation  of  beats.  These 
interpolated  beats,  in  his  experiments  on  frogs,  originated  at  the 
venous  ostia,  as  the  result  of  electric  stimulation  of  the  veins,  caus- 
ing double  the  number  of  ventricular  contractions.  These  experi- 
ments seem  to  have  been  confirmed  by  i  iering  and  Gerhardt. 

To  appreciate  the  situation  better,  it  may  be  well  to  review 
some  of  the  points  bearing  on  the  nerve  supply  of  the  heart.  First 
of  all,  there  are  three  sets  of  nerves  that  inriuence  the  heart:  (i) 
The  pneumogastric  slows  it  and  lowers  arterial  pressure.  (2)  The 
sympathetic  supplies  th,e  accelerator,  quickens  the  action  of  the 
heart,  and  also  furnishes  nerves  that  regulate  the  calibre  of  the  arter- 
ies (Mackenzie)^  (3)  The  ganglia  are  the  intrinsic  nerves  of  the 
heart,  controlling  its  systole  and  contractions.  The  investigations  of 
von  Bezold  and  Alartius  show  that  abstraction  of  the  influence  of  the 
pneumogastric  permits  of  an  increase  of  the  heart-beats  of  only  from 
120  to  180,  while  irritation  of  the  sympathetic  permits  of  an  increase 
of  beats  to  120.  The  action  of  the  ganglia  in  increasing  the  heart- 
rate  is  indeterminate.  While  these  experiments  explain  how  in 
lesions  of  the  pneumogastric  or  its  roots,  the  pulse  may  reach  150 
to  180,  they  fail  to  explain  higher  rates  except  by  the  supposition 
that  the  combinations  of  disturbed  action  of  the  cranial  and  the 
sympathetic  nerves  may  increase  the  rate  beyond  180,  and  they 
also  fail  to  explain  the  cause  of  the  frequent  pulse  wdien  there 
are  no  nerve  lesions  manifest.  Hoffmann's  explanation,  it  is  true, 
as  confirmed  by  Gerhardt  and  Hering,  would  explain  the  cause  of 
high  degrees  of  the  arrhythmic  frequent  pulse,  but  not  of  the  rhyth- 
mic variety.  The  subject  of  these  interpolated  beats  has  been  treated 
of  extensively  by  Cushny*  and  by  Mackenzie^  under  the  name  of 
"premature  pulse." They  are  "dzvarf"  heats  in  that  they  are  dimin- 
utive as  to  dimensions  and  duration,  and  occur  singly  or  in  groups, 
two  or  more  taking  the  place  of  the  regular  beats — as  proved  by  the 
sphygmogram. 

While,  therefore,  new  facts  are  being  brought  forward  from  time 
to  time,  bearing  on  the  cause  of  the  frequent  pulse,  its  pathogenesis 
is  not  yet  completely  understood.  The  full  list  of  causes,  as  given  by 
Larcena*"'  is  as  follows : 

(i)  Tachycardia  in  diseases  of  the  heart  and  blood-vessels.  Un- 
der this  head  is  included  the  increased  action  of  the  heart  which 


'  Mackenzie,  The  Pulse,  Edinburgh,  1902. 

*  Cushny,  Jour,  of  Expcr.  Med.,  1899,  IV.  327. 

'Loc   cit. 

°  Les  Tachycardies.     These  de  Paris,  1891. 


Functional  Cardiac  Diseases  175 

occurs  in  overstrain,  acute  and  chronic  myocarditis,  valvular  dis- 
eases, pericarditis,  angina  pectoris,  acute  and  chronic  aortitis,  arterio- 
sclerosis, and  the  affections  of  the  heart  that  occur  in  Jiright's 
disease. 

(2)  Febrile  tachycardia. 

(3)  Tachycardia  from  peripheric  compression — that  is,  on  one 
or  both  trunks  of  the  vagus — and  from  central  compression  of  its 
nucleus. 

(4)  Tachycardia  from  organic  disease  of  the  nervous  system. 

(5)  Tachycardia  in  general  diseases:  (a)  Acute  diseases,  such  as 
typhoid  fever,  diphtheria;  (b)  chronic  diseases,  such  as  tuberculosis, 
carcinoma,  chlorosis,  syphilis,  chronic  malaria,  chronic  rheumatism 
ofthejomts;  (c)   convalescence  and  exhaustion. 

(6)  Tachycardia:  (a)  From  alcohol,  coffee,  or  tea;  and  ( b) 
from  drugs,  digitalis,  atropine,  etc. 

(7)  Reflex  tachycardia  from  the  brain,  heart,  lungs,  stomach, 
liver,  intestine,  uterus,  abdomen,  bladder,  prostate  gland,  brachial 
plexus ;  and 

(8)  Tachycardia  in  neuroses:  Graves'  disease,  hysteria,  epilepsy, 
and  neurasthenia. 

There  are  three  forms  of  the  frequent  pulse :  the  temporary,  the 
paroxysmal,  and  the  permanent.  An  example  of  the  temporary  is 
the  frequent  pulse  resulting  from  any  violent  exertion.  Examples 
of  the  paroxysmal  form  are  seen  in  neurasthenic  states,  in  which 
there  is  a  sudden  frequency  of  the  pulse  and  a  sudden  decline,  last- 
ing hours,  days,  weeks,  or  months,  and  often  leaving  the  patient 
exhausted  and  sometimes  with  a  dilated  heart.  The  permanent  form 
is  frequently  seen  in  chronic  tuberculosis,  in  which  there  may  be 
no  considerable  rise  of  temperature ;  or  in  tertiary  syphilis  with 
pulmonary  complications.  This  latter  form  of  frequent  pulse  con- 
tinues to  the  end  of  life. 

In  the  paroxysmal  varieties  the  pulse  is  usually  small  and  com- 
pressible, due  probably  to  imperfect  filling  of  the  vessels.  In  30 
cases  given  by  Martins  it  ranged  from  80  to  180 ;  the  average  being 
from  120  to  140.  The  pulse  frequently,  however,  may  reach  300 
and  more.  Bristowe  has  recorded  a  pulse  of  308,  but  this  is  very 
exceptional.  Such  pulses  can  only  be  counted  with  the  sphygmo- 
graph. 

The  frequent  pulse  may  occur  in  childhood,  middle  age.  or  ad- 
vanced years.  Broadbent  has  recorded  a  case  at  10  years  of  age 
and  another  at  81. 


176  Functional  Cardiac  Diseases 

In  the  paroxysnially  frequent  pulse  the  symptoms  vary.  Al- 
most all  the  patients  are  anxious  and  complain  of  lassitude.  There 
is  often  pr^ecordial  oppression.  Some  patients  are  cyanotic,  others 
are  not.  Some  attend  to  business  as  usual.  The  lungs  are  usually 
free.  Among  German  writers  such  as  Riegel  and  Martins^  there 
have  been  noted  instances  of  pulmonary  emphysema,  which  appeared 
with  the  frequent  pulse  and  disappeared  with  it.  Martius  gives  three 
cases.  It  is  well,  however,  to  keep  in  mind  that  in  Germany  clini- 
cians are  apt  to  rely  on  a  low  position  of  the  liver  in  their  diagnosis 
of  emphysema,  a  sign  ihat  elsewhere  is  not  regarded  of  so  nnich 
importance. 

In  eight  of  Martins'  cases  there  was  cardiac  dilatation,  which  was 
a  proof  that  the  cases  were  severe.  Among  other  signs  that  have 
been  noted  are  venous  thromboses,  swelling  and  pulsation  of  the 
veins  of  the  neck,  albuminuria,  and  oedema. 

There  is  much  to  learn  in  the  matter  of  treatment.  As,  however, 
pressure  on  the  pneumogastric  nerve  wall  reduce  pulse  frequency, 
it  has  been  tried  and  with  temporary  success.  Iced  water  and  strong 
coffee  have  sometimes  been  effective ;  so  have  Hoffman's  anodyne 
and  diffusible  and  alcoholic  stimulants.  Dr.  W.  H.  Thomson,  of 
New  York,  in  a  record  of  six  cases  of  tachycardia  associated  with 
various  forms  of  neurasthenia,  ascribes  the  disease  to  gastro-intes- 
tinal  intoxication,  and  reports  success  under  the  use  of  the  sali- 
cylates, especially  strontium  salicylate  in  15-grain  doses,  weak  mer- 
curials, intestinal  antiseptics,  and  a  carefully  regulated  diet, 
which  excluded  highly  nitrogenous  food.  On  the  other  hand, 
when  the  frequent  pulse  is  reflex,  so  that  we  can  ascribe  it  to 
non-toxic  diseases  of  the  stomach,  kidneys,  ovaries,  uterus,  or  other 
organ  of  the  abdominal  or  pelvic  cavity,  it  may  be  due  to  arterial 
hypertension  (Huchard),  or  vasomotor  paresis.  Clement  and 
Hirsch  attribute  the  pulse  to  mere  excitement  of  the  nervous 
system.  In  the  permanently  afebril  frequent  pulse  it  may  be  im- 
possible to  reduce  the  pulse-rate  materially ;  but  we  must  always 
keep  in  mind  that  it  is  merely  a  symptom  and  not  necessarily  a  dis- 
tressing one.  Nor  should  we  attempt  by  the  use  of  drugs,  such  as 
hellebore,  digitalis,  and  the  like,  to  reduce  cardiac  frequency;  for  in 
so  doing  we  only  increase  personal  discomfort  without  accomplish- 
ing any  useful  purpose.  If,  however,  the  constitutional  affection,  be  it 
tuberculosis,  syphilis,  or  any  exhausting  disease,  improves,  the  pulse 
will  fall  at  a  rate  corresponding  to  the  improvement.  It  is  the  gen- 
eral condition  of  the  patient,  therefore,  for  which  we  should  be  so- 

''  Ber!.  klin.  JVoch.,  1875,  No.  31. 


Functional  Cardiac  Diseases  177 

licitous,  rather  than  his  pulse.  A  pulse  of  120  to  130  does  not  neces- 
sarily distress,  and  it  may  not  be  inconsistent  with  a  fairly  active  life. 

The  prognosis  is  unfavorable  in  recurrent  cases,  but  a  man  may 
possibly  live  with  it  to  the  age  of  81  years,  and  recovery  may  take 
place  from  a  pulse-rate  of  260. 

The  following  case,  taken  from  my  hospital  records,  is  an  exam- 
ple of  periodic  palpitation,  of  a  severe  character : 

Case  LIV.  Paroxysmal  Afebrile  Palpitation;  Aortic  Endo- 
carditis; Embolism;  General  Dropsy. — C,  a  young  man,  was  admit- 
ted to  hospital  in  January,  1875.  tie  gave  a  history  of  violent  ex- 
ercise, such  as  running  up  and  down  stairs  on  wagers.  He  had  led 
a  dissipated  life.  Three  months  previously  he  first  experienced 
dyspnoea  and  palpitation  on  exercise,  so  that  at  length  he  was  unable 
to  go  upstairs  without  losing  his  breath.  The  pulse  at  the  wrist 
was  found  to  be  140,  with  quick-drop  beats,  when  he  was  perfectly 
quiet  and  composed,  but  in  attacks  of  palpitation  the  frequency  would: 
reach  180  to  200,  and  then  it  caused  prsecordial  pain  and  dyspnoea. 
From  three  to  ten  attacks  would  occur  at  night.  His  face  was  pale 
and  swollen,  and  his  legs  oedematous.  Orthopnoea.  The  patient 
died  in  coma. 

At  the  post-mortem  examination  the  pericardium  was  found  to 
contain  8  ounces  of  fluid.  The  heart  was  greatly  dilated.  Tremen- 
dous infiltration  of  aortic  valves  was  present — one  fringe-like  mass 
waving  to  and  fro  in  the  blood  current.  The  spleen  and  the  liver 
were  the  seat  of  old  and  new  embolic  processes. 

I  have  reported  two  cases  of  the  temporarily  frequent  pulse* 
due  to  fatty  heart.  In  one,  a  lady  of  65,  the  pulse,  which  before 
treatment  by  carbonated  baths  and  exercises  was  as  high  as  104, 
fell  after  treatment  to  an  average  of  81.  In  the  other,  a  gentleman 
weighing  237  pounds,  with  a  pulse  of  100,  experienced  after  a  simi- 
lar treatment  a  drop  of  70,  while  the  quality  improved,  and  dyspnoea 
disappeared.      (Cases  XXXVH  and  XXX VHI.) 

The  following  cases,  also  from  my  hospital  and  private  records, 
illustrate  some  of  the  more  important  varieties  of  the  frequent  pulse : 

Case  LV.  The  Paroxysmally  Febrile  Frequent  Pulse  of  Urce- 
mia;.  Endocarditis. — A  young  widow,  aged  31  years,  was  admitted 
to  hospital  in  May,  1884,  in  a  comatose  condition  and  with  partial 
suppression  of  urine.  A  systolic  murmur  was  noted  at  the  apex.  Two 
days  later  ursemic  convulsions  set  in,  and  continued  with  few^  inter- 
missions until  death.    With  the  first  convulsion  the  pulse  was  1 18 ; 


Post-Graduate,  March,   1899. 


1/8  Functional  Cardiac  Diseases 

it  rose  to  132,  with  the  rosj)irations  34,  aiul  the  tiMuperature  102°  F. 
Before  death  the  pulse  fell  to  104.  the  temperature  rose  to  103.8° 
F.,  and  the  respiration  to  50.  At  the  post-mortem  examination 
endocarditis  of  the  mitral  and  aortic  valves  was  found,  but  both 
valves  were  sufficient.  The  valvular  difficulty  must  therefore  have 
played  a  subordinate  role.  Tlie  kidneys  showed  the  usual  signs  of 
chronic  diffuse  nephritis.  The  frequency  of  the  pulse,  it  will  be 
seen,  was  not  proportionate  to  the  fever,  so  that  it  is  fair  to  assume 
that  the  frequent  pulse  w^as  due  to  the  uraemia. 

Case  LI' I.  Afebrile  Frequent  Pulse;  Aortic  and  Mitra!  Endo- 
carditis; Urccmia. — C,  a  widow,  aged  48  years,  was  admitted  to  hos- 
pital June  2/,  1885.  Three  months  before  admission  she  w^as  taken 
ill  with  cough,  expectoration,  night  sweats,  and  dyspnoea  on  exer- 
tion. The  urine  was  diminished  and  the  feet  were  swollen.  The 
heart  was  found  enlarged,  and  a  loud  mitral  systolic  murmur,  con- 
veyed to  the  left,  was  heard.  There  was  also  an  aortic  direct  mur- 
mur carried  up  the  great  vessels,  and  the  veins  of  the  neck  pulsated. 
The  liver  was  enlarged.  The  pulse  was  irregular,  128.  The  urine 
contained  albumin  (25  per  cent.),  and  hyaline  and  granular  casts. 
At  the  post-mortem  examination  the  ante-mortem  evidences  of 
aortic  and  mitral  disease,  enlarged  liver  and  diffuse  nephritis,  were 
confirmed.  This  case  w^as  afebrile,  so  that  the  frequent  pulse  was 
probably  due  to  the  uraemia. 

In  the  following  two  cases  it  is  probable  that  the  paroxysmally 
frequent  pulse,  thougli  febrile,  was  due  to  pericarditis: 

Case  LVII.  Febrile  Frequent  Pulse;  Acute  Articular  Rheuma- 
tism; Acute  Serofibrinous  Pericarditis;  Acute  Diffuse  Nephritis. — 
M.,  aged  39  years,  a  painter,  was  admitted  to  hospital  November 
19,  1883.  Tw^o  weeks  before  admission  he  was  taken  ill  with  a  sharp 
attack  of  acute  articular  rheumatism.  On  examination  the  joints 
were  found  swollen.  There  was  also  a  blue  line  on  the  gums.  The 
heart's  action  w^as  feeble.  The  urine  had  a  specific  gravity  of  1030 
and  contained  albumin.  On  November  27  double  friction  sounds 
over  the  apex,  not  transmitted,  were  heard.  The  pulse  was  120,  the 
temperature  101°  F.,  and  the  respiration  44.  On  November  28 
the  patient  became  delirious,  the  friction  sound  was  not  so  distinct, 
and  the  temperature  was  106°  F.  Until  death,  November  30,  the 
pulse  continued  to  be  rapid  and  feeble.  At  the  post-mortem  exam- 
ination there  w^as  found  oedema  of  the  lungs,  chronic  diffuse  nephri- 
tis, and  a  fatty  liver.  The  pericardial  sac  contained  15  ounces  of 
clear  serum.      Both  parietal  and  visceral  layers  were  covered  with 


Functional  Cardiac  Diseases  179 

plastic  material.  The  case  was  regarded  as  a  typical  example  of 
the  "hairy  heart,"  and  to  this  acute  pericarditis  was  attributed  the 
frequent  pulse. 

Cas€  LVIII.  Rupture  of  a  Cyst  in  the  Broad  Ligament;  Peritoni- 
tis; Septicmnia-;  Acute  Fibrous  Pericarditis;  Paroxysmally  Frequent 
Pulse. — B.,  colored,  aged  30  years,  was  admitted  to  the  hospital 
April  16,  1878.  About  three  months  previously  she  had  noticed  a 
tumor  in  her  abdomen,  and  since  then  had  suffered  from  several  at- 
tacks of  peritonitis.  •  There  was  cough  with  reddish  expectoration. 
The  temperature  was  99°  F.,  the  pulse  13d,  and  the  respiration  40. 
On  April  22  the  temperature  was  101.6°  F.,  the  pulse  150  to  160,  and 
the  respiration  2,2;  on' April  23  the  temperature  was  101°  F.,  the 
pulse  140,  and  the  respiration  40 ;  on-  April  24  the  temperature  was 
101°  F.,  the  pulse  136,  and  the  respiration  28.  During  the  suc- 
ceeding six  days  the  pulse  varied  from  136  to  140,  and  the  tempera- 
ture between  99"  and  100°  F.  The  patient  died  on  May  6,  and  at 
the  post-mortem  examination  several  pints  of  pus  were  found  in  the 
abdominal  cavity,  with  cysts  of  the  broad  ligament,  one  of  which  had 
ruptured.  The  two  confronting  layers  of  the  pericardium  were  cov- 
ered with  a  fresh  "hairy  growth."  In  this  case,  as  in  the  preceding, 
the  pulse-rate  persisted  between  136  and  160,  although  the  tempera- 
ture fell  as  low  as  97.8°  F.,  and  did  not  reach  103°  F. 

Intances  of  the  permanently  frequent  pulse  are  not  rare.  We  all 
meet  with  them  in  advanced  tuberculosis. 

Syphilis  is  prone  in  its  later  stages  to  produce  a  permanently  fre- 
quent pulse.  Such  a  case  came  to  me  for  treatment  in  1897,  and 
continued  under  my  care  for  upward  of  two  years.  The  pulse  at  the 
beginning  of  treatment  averaged  between  125  and  130,  but  fell  to 
an  average  of  iii,  under  treatment  by  carbonated  baths  and  resist- 
ance exercises.  The  patient  had  locomotor  ataxia,  luetic  phthisis, 
mitral  endocarditis,  and  arterio-sclerosis.  But  with  this  complica- 
tion of  lesions  he  managed  at  times  to  attend  to  a  pretty  active  busi- 
ness.   Death  was  due  to  an  intercurrent  affection.     (Case  XLVII.) 

In  another  case,  also  one  of  locomotor  ataxia,  which  I  saw  at 
the  instance  of  a  well-known  specialist,  the  patient  had  been  ill  for 
15  years,  and  10  years  previously  had  had  violent  pains  in  her  head 
with  diplopia,  followed  2  years  later  by  lightning  pains,  and  after 
another  2  years  by  ataxia.  Her  pulse  maintained  a  pretty  uniform 
rate  of  100  when  in  bed,  where  she  was  confined  by  paresis  of  the 
muscles  of  the  lower  extremities. 


l-8o  Functional  Cardiac  Diseases 

The  following  case  oi  permanently  frequent  pulse  is  particularly 
interesting,  because  a  post-mortem  examination  was  obtained : 

Case  LIX.  Syphilitic  Phthisis  and  Mcuingitis;  Aortic  and  Mi- 
tral Endocarditis;  Permanently  Frequent  Pulse. — K.,  aged  28  years, 
an  artist,  was  admitted  to  the  hospital  April  7,  1884.  The  patient  had 
contracted  syphilis  and  was  intemperate.  For  five  years  his  pulse 
had  been  irregular.  Five  days  before  admission  he  had  a  hemopty- 
sis. The  haemorrhage  was  controlled  by  ergot,  and  the  patient 
improved  so  much  as  to  gain  20  pounds.  But  during  the  last  six 
months  of  life  his  pulse  rose  to  150,  and  he  became  dyspnoeic.  Dur- 
ing the  last  ten  days  the  pulse  ranged  from  141  to  150,  and  he  was 
delirious.  At  the  post-mortem  examination  the  lungs  and  the  liver 
showed  gummas.  The  patient  died  of  syphilitic  phthisis  and  cere- 
bral meningitis,  and  the  former  was  held  to  have  caused  the  frequent 
pulse,  which  is  not  an  uncommon  sign  in  advanced  syphilis. 


Chapter  XVI. 
PULSUS  INFREQUENS.* 

The  prevailing  terminplogy  of  this  affection  is  unfortunate.  I 
refer  to  the  words  Bradycardia^  and  Spanocardia  that  are  in  usq. 
and  I  may  say  the  §ame  of  Araiocardia  and  Ohgocardia,  that  have 
been  suggested. 

The  use  of  the  termination  cardia^  impHes  that  the  key  to  the 
actions  of  the  arterial  current  is  to  be  found,  from  a  clinical  point 
of  view,  in  the  heart,  rather  than  in  the  peripheral  arteries.  And 
yet  a  comparison  between  the  readings  of  recording  instruments  that 
register  the  heart  and  pulse  beats  simultaneously,  as  shown  by 
Mackenzie^  and  others,  illustrates  that  there  may  be  a  wide  variation 
as  to  frequency  and  rhythm  between  the  two. 

To  illustrate,  a  double  contraction  at  the  left  ventricle  may  be 
registered  in  a  sphygmogram,  as  a  single  one ;  while  a  cardiogram 
will  show  cardiac  contractions  of  which  there  are  no  traces  in  the 
sphymogram.  This  latter  circumstance,  characteristic  of  the  "in- 
termittent pulse"  (to  be  distinguished  from  the  "deficient  pulse" 
where  both  cardiac  contraction  and  the  pulse  beat  are  simultane- 
ously "missed")  is,  of  course,  very  common.  Now  though  the  heart 
regulates  the  general  circulation,  its  essential  characteristics  are 
better  exhibited  at  the  periphery  than  at  the  center.  And  for  two 
reasons.  The  peripheral  arteries  are  more  accessible,  and  therefore 
can  be  more  conveniently  studied  than  the  heart,  and  they  give  us 
more  information  because  cardiac  action  studied  at  a  distance  can  be 
better  appreciated.  It  is  not  uncommon  to  judge  of  motive 
forces  by  their  remote  effects.  In  telegraphing  or  telephoning,  the 
one  who  transmits  the  message  cannot  judge  of  the  quality  of  the 
instrument  so  well  as  the  one  who  receives  it.  And  so  clinically, 
blood  circulation  is  better  estimated  by  the  pulse  than  by  the  heart ; 
so  that  there  is  a  reasonable  objection  to  the  use  of  all  terms  ending 
in  cardia.  But,  apart  from  this,  the  qualifying  prefixes  are  either 
improper,  as  in  the  use  of  brady,  or  are  vague  in  meaning.      True 


*  Originally  published  in  the  Albany  Medical  Annals,  March.   1903. 

^  Introduced  by  Grob,  Veutsch.  Archiv.  fiir  klinische  Medicin,  1888.  XLII., 

p.  574- 

'  Kardios,  heart ;  brados,  slow ;  spanos,  deficient ;  araios,  rare ;  obliges,  few. 
^  Mackenzie,  Study  of  the  Pulse,  Edinburgh  and  London,  1902. 


i82  Pulsus  Infrequens 

Bradycardia  implies  that  the  ventricular  contraction  is  prolonged 
bevond  the  usual  time,  in  other  words,  that  it  is  slow  ;  but  so  far 
as  I  know,  slow  ventricular  contraction  occurs  only  in  aortic  stenosis 
or  in  aneurisms  near  the  aortic  orifice,  where  some  obstruction  like 
an  atheromatous  plate  narrows  the  lumen  of  the  vessels,  the  con- 
traction of  the  left  ventricle  being  necessarily  prolonged,  in  order 
to  permit  it  to  force  the  column  of  blood  through  the  constricted 
passage. 

This  is  not,  however,  the  common  acceptance  of  the  term,  which 
is  simply  that  the  number  of  pulse  beats  to  the  minute  is  abnormally 
small.  As  a  matter  of  fact,  pulse  beats,  in  the  infrequent  pulse,  may 
be  quick  or  slow. 

To  my  mind,  of  all  the  terms  suggested  no  one  expresses  thi^ 
numerical  deficiency  so  well  as  the  Latin  Pulsus  Infrequens,  the 
infrequent  pulse. 

The  pulse  rate,  as  is  well  known,  varies  more  or  less  according 
to  circumstances,  such  as  the  age  and  height  of  the  individual, 
atmospheric  temperature,  the  time  of  day,  and  acquired  or  inherited 
peculiarities.  In  the  adult  male  the  standard  is  set  at  seventy-two; 
in  the  adult  female,  at  seventy-six  to  eighty.  And  yet  it  is  by  no 
means  rare  for  a  person  in  apparently  good  health  to  have  a  pulse 
anywhere  in  the  sixties.  By  general  consent,  however,  a  pulse  below 
sixty  is  regarded  as  infrequent. 

T!"ie  pidsiis  infrequens  may  occur  at  almost  any  period  of  life. 
Prentiss',  has  reported  one  instance  at  sixteen  months.  It  was 
caused  bv  an  injury  to  the  neck,  followed  by  an  abscess  between  the 
medulla  and  pons. 

Grob.  from  elaborate  study,  has  found  that  it  may  occur  as  late 
as  ninety,  but  usually  between  twenty  and  forty.  In  my  experience 
it  is  more  often  seen  in  the  middle  period  of  life,  or  after  it. 

The  infrequent  pulse  in  adults  (where  the  rate  falls  below  40) 
is  rare,  though  most  practitioners  with  large  experience  have  prob- 
ably seen  occasional  instances  at  some  time  or  other.  If,  however, 
we  should  adopt  sixty  as  the  figure  below  which  all  pulses  are  to  be 
reckoned  as  infrequent,  we  would  find  them  comparatively  common. 
According  to  Grob's  experience  about  one  individual  in  forty''  has 
an  infrequent  pulse.  Thus  far  it  has  been  unfortunate  that  most 
observers  have  failed  to  note  the  relation  in  number  per  minute  be- 
tween the  pulse  and  heart  beats,  though  the  importance  of  ascertain- 


*  Prentiss,  Transactions  of  American  Physicians,  i88g,  p.  120. 
°  Grob,  82  in  3,578  patients. 


Pulsus  Infrequens  183 

ing  this  variation  was  pointed  out  by  Stokes"  in  1846,  when  he  told 
of  a  patient  whose  heart  beats  were  thirty-six  to  the  minute  while 
the  pulse  was  twenty-eight.  Since  that  date  the  importance  of  this 
point  has  been  emphasized  sufficiently  to  have  merited  general  at- 
tention. 

P'our  different  relations  may  be  observed  between  the  action  of 
the  pulse  and  the  heart:  (i)  The  heart  and  pulse  may  beat  simul- 
taneously. (2)  The  heart  beats  may  not  all  be  communicated 
to  the  wrist.  (3)  The  auricles  may  pulsate  more  frequently  than 
the  ventricles  and  arteries.  (4)  Contractions  of  the  several  cham- 
bers may  occur  when  the  heart  has  been  removed  from  the  body. 
In  fact,  even  when  the  muscular  tissue  of  the  walls  of  the  heart 
has  been  cut  into  small  pieces,  they  may  be  made  to  contract  by  vari- 
ous stimuli, — a  fact  that  has  been  known  since  the  time  of  Vesalius. 

The  first  two  of  these  statements  have  been  satisfactorily  proved 
by  clinical  experience ;  the  last  two  by  physiological  experimen- 
tation, where  electrical  currents  and  othe'r  stimuli  have  been  known 
to  produce  muscular  contractions  hours  after  death. 

The  infrequent  pulse  has  two  principal  varieties,  the  physiolog- 
ical and  the  pathological. 

Of  the  first  two,  we  have  two  well-known  instances,  the  infre- 
quent pulse  of  inheritance  and  the  pulse  of  pregnancy. 

Prentiss  has  recorded  several  instances  where  persons  whose 
pulses  averaged  thirty  to  thirty-two  were  in  apparently  sound  health, 
and  historians  tell  us  not  only  that  Napoleon's  pulse  was  forty  even 
in  the  midst  of  a  battle,  but  that  he  felt  uncomfortable  when  it  rose 
to  sixty.  The  most  remarkable  instance,  however,  is,  I  think,  that 
recorded  by  Vigouroux,'^  who  had  under  his  observation  a  laborer 
whose  pulse  never  exceeded  twenty.  The  man  never  experi- 
enced any  illness  so  far  as  he  knew,  excpt  on  one  occasion  when 
he  had  a  short  and  slight  gastric  attack,  which  w^as  successfully 
treated.  In  this  connection  it  is  interesting  to  remember  that 
Czermak^  could  stop  the  action  of  his  heart  for  a  few  beats  by 
pressure  on  the  pneumogastric,  and  Quincke^  has  verified  this  ex- 
periment. Besides,  the  heart  has  been  stopped  by  stopping  the 
respiration. 

The  infrequent  pulse  is  more  common  in  males  than  in  females, 
the  ratio  being  about  five  to  one,  according  to  Prentiss's  tables. 


°  Stokes,  On  the  Heart,  etc.,  1855,  p.  329. 

'  Vigouroux.  Gazette  des  Hopitaux.  876,  p.  788. 

^  Czermak,  Viertel  Jahresch.  fur  pract.  Heilkundc.  1863,  p.  190. 

^  Quincke,  Berliner  klinische  Wochenschrift,   1875,  No.   15,  p.   190. 


184  Pulsus  Infrequens 

Of  the  pathologfical  we  have  two  subdivisions,  the  Paroxysmal, 
Periodic  or  Temporary,  and  the  Chronic  or  Essential.  Under  the 
causes  of  the  former  come  the  infections,  typhoid,  diphtheria,  pneu- 
monia, erysipelas,  pueqjerai  affections  and  influenza,  best  seen  dur- 
ing^ convalescence ;  toxremias  from  lead,  tobacco,  tea,  coffee,  digi- 
tahs,  uraMnia,  cholesterremia  and  syphilis ;  functional  nervous  dis- 
turbances ;  retlex  influences  from  the  skin  or  gastro-intestinal  tract ; 
and  temjjorary  debility. 

Among  the  causes  of  the  chronic  or  essential  variety  are  organic 
diseases  of  the  brain  and  cord.  According  to  Prentiss  the  infrequent 
pulse  is  due  chiefly  to  organic  diseases  of  the  brain  or  cord,  epilepsy 
and  organic  heart  affections,  though  in  eighty-nine  of  his  cases  the 
cause  was  stated  to  be  unknown  in  thirty-five. 

Grob  in  his  etiology,  based  on  personal  observations,  is  quite 
definite  on  this  point.  In  a  series  of  100  cases  he  has  put  the 
etiological  factors  as  follows,  as  to  relative  frequency : 

Physiological    6 

Idiopathic    i 

Articular  rheumatism   24 

Circulatory  disturbances   I 

Digestive  disturbances   10 

Diseases  of  the  central  nervous  system 6 

Infections  and  constitutional  diseases 9 

Convalescence  from  typhoid  especially,  but  also  diph- 
theria, measles,  pneumonia,  and  erysipelas 43 


100 


The  paroxysmally  infrequent  pulse,  according  to  (jrob,  repre- 
sented 112  out  of  140  of  his  cases.  His  experience  that  the  par- 
oxysmally infrequent  pulse  largely  predominates  coincides  with 
my  own  views.  The  pulse  rate  in  these  instances  is  subject,  under 
pathological  conditions,  to  wide  variations  in  range,  while,  as  we 
have  seen,  under  physiological  conditions  it  maintains  a  tolerably 
steady  rate.  In  the  first  named  conditions  very  low  rates  have 
been  recorded.  Holbertson  has  published  one  instance  where  the 
pulse  fell  on  one  occasion  to  seven  and  one-half  in  a  patient  who 
had  attacks  of  vertigo  and  loss  of  consciousness  following  an  ac- 
cident on  the  hunting  field.  At  the  ])Ost-mortem  examination  it 
vi'as  found  that  there  had  been  pressure  on  the  medulla  and  upper 


Pulsus  Infrequens  185 

part  of  the  cord,  the  result  of  fracture  of  the  occipital  bone  and 
upper  cervical  vertebra.  Bony  union  of  the  parts  had  ensued,  but 
with  displacement  of  the  fragments.  Other  instances  have  been 
published  where  the  pulse  fell  as  low  as  to  iour,^"  and  even  three.^^ 
This  last  case  was  one  of  the  paroxysmal  variety,  and  the  patient 
rallied  from  the  attack. 

The  explanation  of  the  infrequent  pulse  is  not  simple.  We  can 
realize  that  pressure  on  the  pneumogastric  may  cause  it,  as  in 
Czermak's  and  Quincke's  experience,  and  there  are  many  instances  in 
which  there  was  organic  disease  at  the  base  of  the  brain  from 
pressure  by  bone,  as  in  Holbertson's  case.^-  This  nerve  passes  from 
its  root  in  the  medulla  down  to  the  cardiac  plexus.  The  augmentor 
(accelerator)  fibres  of  the  sympathetic  also  pass  down  from  near 
the  same  spot  to  the  cardiac  plexus,  supplying  energy  to  the  muscular 
tissue  of  the  heart,  though  the  precise  course  of  the  fibres  is  un- 
known.     Possibly  they  pass  down  through  the  cord. 

The  pneumogastric  regulates,  i.  e.,  moderates  or  restrains,  the 
energy  of  the  heart,  thereby  slowing  the  pulse. 

The  function  of  the  intrinsic  ganglia  in  the  heart  substance  is  not 
yet  understood.  They  may  supply  motor  energy  to  the  heart,  inde- 
pendently of  the  spinal  nerves  or  the  sympathetic.  And  yet  they  ap- 
pear to  lose  vitality  after  separation  from  the  peripheral  nerve 
system.  Certainly  the  heart  beats  in  the  foetus,  before  any  trace  of 
nerve  fibres  can  be  found.  Lastly,  it  appears  that  the  muscle  tissue 
of  the  heart  may  assume  the  initiative,  acting  independently  of  any 
nervous  influence,  as  recent  experiments  would  seem  to  prove.  The 
paroxysmal  cases  may  be  due  to  reflex  excitations  of  the  pneumo- 
gastric, though  the  stimulus  of  almost  any  afferent  (sympathetic) 
nerve,  (such,  for  example,  as  the  abdominal  sympathetic),  may 
cause  them.  For  a  blow  on  the  abdomen  conveys  the  impulse  to 
the  medulla  through  the  pneumogastric.  slowing  or  stopping  cardiac 
action.  These  attacks  may  also  be  due  to  depression  of  the  aug- 
mentors,  such  as  occur  in  nervous  or  muscular  strain,  and  in  gastro- 
intestinal irritation.  They  may  also  be  caused  by  diminished  action 
of  the  accelerators.  In  the  permanently  infrequent  pulse  we  appear 
to  have  these  causes  in  continuous  action. 

There  may  or  may  not  be  symptoms.      In  the  ph}-siologically 


"W.  Henry  Day,  British  Medical  Journal,  1880,  Vol.  I.,  p.  113.  The  pulse 
beat  four  times  a  minute  for  about  four  minutes  during  an  attack  of  un- 
consciousness. 

"  Prentiss,  in  case  seventy-nine. 

"  Holbertson,  Medico-Chirurgical  Transactions,  Vol.  XXIV..  p.  -6. 


i86  Pulsus  Infrequens 

infrequent  pulse,  such  as  the  hcrcihtary.  or  cong-enital,  or  pulse 
of  pregfiiancv.  there  are  no  untoward  symptoms.  In  fact,  evidence 
goes  to  show  that  in  most  of  them,  or  certainly  in  many,  an  in- 
crease in  rate  begets  no  disagreeable  sensations. 

On  the  other  hand,  the  infrequent  pulses  of  the  infections,  such 
as  typhoid  and  the  tox;cmias.  j^oisoning  by  tobacco,  digitalis,  tea 
or  coffee,  uraemia  and  anaMiiia,  cholesteraemia  and  syphilis,  are  so 
wrapped  up  in  the  symptomatology  of  their  several  affections  that 
a  description  of  their  several  symptoms  would  carry  us  beyond 
the  scope  of  this  chapter. 

We  have  now  to  consider  the  remaining  forms  of  the  neuroses 
(the  so-called  idiopathic  varieties),  a  definition  which,  from  a 
theoretical  point  of  view,  fits  them  conveniently  enough,  because 
they  may  turn  out  to  be  due  to  refiex  excitations,  as  from  gastro- 
intestinal disturbances,  or  skin  diseases,  or  to  direct  excitations 
as  after  severe  muscular  ex:ercises  or  nervous  strain.  In  these  lat- 
ter cases  the  symptoms  are  those  of  general  lassitude,  prostration, 
praecordial  oppression,  a  sense  of  constriction,  choking  and  dyspnoea, 
and  are  apt  to  be  associated  with  nervous  strain. 

On  the  other  hand,  the  results  of  severe  muscular  exercise  are, 
according  to  Huchard,  apt  to  be  reflected  in  the  nervous  system  by 
attacks  of  vertigo,  convulsions,  unconsciousness,  of  short  or  long  du- 
ration, epileptiform  or  apoplectiform  seizures,  loss  of  rhythm,  a  sys- 
tole associated  with  varying  rates  of  infrequency  of  pulse,  Cheyne- 
Stokes  respiration,  with  a  synchronous  pulsation  of  auricles  and  ven- 
tricles, which  come  on  without  w^arning  or  with  an  ill-defined  aura.^^ 
This  latter  variety  has  now  been  erected  into  a  group  under  the 
name  of  the  Adams-Stokes  syndrome,^*  because  these  two  men 
were  the  first  to  describe  it.  Cases  of  this  variety  may  survive  for 
several  years. 

I  saw  a  case  with  some  of  these  features  many  times  in  consulta- 
tion in  1901  (Case  LX).  An  old  gentleman  with  arterio-sclerosis, 
during  a  prolonged  attack  of  heart  failure,  with  a  pulse  in  the  thir- 
ties, while  the  heart  beats  were  not  far  from  normal,  developed 
orthopnoea  ascites  and  Cheyne-Stokes  breathing  during  a  period  of 
unconsciousness  that  last  over  a  week.  But  recovery  took  place,  and 
after  about  two  years  his  physician  reported  that  he  was  in  fairly 
good  health,  driving  in  the  park  in  good  weather,  and  going  to  the 
theatre  when  he  felt  so  inclined.     Digitalis  was  used  in  small  doses 


"His.  Jr..  Deufsch.  Archiv.  fiir  kUnische  Medicin.,  Vol.  64,  p.  316. 
"  Huchard,  Mai.  du  Cceur,  Paris,  1893,  p.  309. 


Pulsus  Infrequens  187 

for  the  ascites  for  brief  periods  only,  the  treatment  otherwise  being 
symptomatic, . 

As  a  matter  of  fact,  the  Adams-Stokes-  syndrome  is  a  complex 
of  symptoms,  consisting  essentially  of  loss  of  consciousness,  dysp- 
ncea^  with  the .  infrequent  pulse.  In  some  cases,  as  in  No.  LX, 
there-  was  Cheyne-Stokes  breathing  in  addition.  Many  varieties 
have  been  described.  The  disease  is  usually  one  of  old  age,  but 
it- is  said  it  may  occur  at  any  time  of  life.  The  attacks,  though 
alarming,  are  not  necessarily  fatal,  but  they  imply  that  the  central 
nervous  system  is  involved.  Adams,  in  1827,  was  the  first  to  de- 
scribe it,  but  Stokes  put  it  prominently  before  the  profession.  How- 
ever, it  was  forgotten  until  recently,  when  it  was  revised  by  Hu- 
chard. 

On  the  other  hand,  there  is  a  group  that  seem  to  be  dependent  on 
gastro-intestinal  irritation,  and  its  signs  are  flatulence,  acid  dys- 
pepsia, nausea  and  vomiting. 

The  diagnosis  offers  no  difficulties,  but  we  should  never,  in  these 
cases,  rest  satisfied  until  we  have  examined  the  heart,  to  find  whether 
it  beats  synchronously  with  the  pulse.  The  sphygmograph  applied 
first  to  pulse  and  then  to  heart  will  be  instructive  in  these  instances. 
We  should  also  carefully  inquire  into  the  possible  causes,  finding  out 
first  whether  it  is  physiological  or  pathological,  and  if  the  latter, 
whether- it  is  not  merely  one  of  the  symptoms  of  the  several  diseases 
that  have  been  enumerated.  Of  the  prognosis  but  little  can  be  said 
because  the  details  are  very  scanty.  In  the  physiological  variety 
it  is  favorable  so  far  as  we  know,  but  the  instances  are  few,  and  the 
expectation  of  life  has  not  yet  been  worked  out. 

In  the  paroxysmal  forms  the  prognosis  depends  upon  our  success 
in  mastering  the  disease  of  which  it  is  a  symptom,  and  each  affec- 
tion gives  a  different  expectation.  For  example,  the  infrequent 
pulse  of  digitalis  or  tobacco  ceases  when  these  herbs  are  withdrawn 
and  in  the  infections  it  ceases  with  established  convalescence ;  w'hile 
in  chronic  diseases  like  lithsemia,  uraemia,  and  syphilis  a  good  out- 
look can  be  assured  only  when  these  diseases  are  held  under  firm 
control.  Now  if  the  physiological  variety  together  with  the  parox- 
ysmal represent,  as  according  to  Grob  they  appear  to,  more  than 
eighty  per  cent,  of  the  cases,  the  prognosis  is  on  the  whole  favorable. 
The  permanently  pathological  form  has  a  less  favorable  prognosis. 

In  the  treatment  no  greater  mistake  can  be  committed  than  to 
aim  at  acceleration  of  the  pulse  by  medication.  Experience  has 
abundantlv  shown  that  such  treatment  invariably  has  bad  results. 


1 88  Pulsus  Infrequens 

The  physiological  cases  require  no  special  treatment,  and  even  the 

pathological  appear  to  do  best  when  let  alone,  so  far  as  the  frequency 
of  the  pulse  is  concerned. 

Especially  when  the  infrequent  pulse  is  associated  with  a  rec- 
ognized affection  or  condition  like  typhoid  fever,  or  lithsemia, 
syphilis,  gastro-intestinal  irritation,  skin  disease  or  anaemia,  the  treat- 
ment apposite  to  the  underlying  affection  will  affect  the  pulse 
favorably,  and  no  special  medication  for  the  infrequency  is  neces- 
sary. Even  alcoholic  or  diffusible  stinuilants  should  be  used  with 
caution.  The  nitrites  and  bromides  are  safer,  but  it  is  always 
better,  so  far  as  possible,  to  treat  the  underlying  disease,  without 
special  reference  to  the  infrequency  of  the  pulse. 

When,  however,  we  have  reason  to  suspect  that  the  infrequent 
pulse  is  due  to  a  functional  nervous  disturbance,  or  are  in  doubt 
as  to  its  exact  cause,  sedatives  like  the  monobromate  of  camphor, 
asafoetida,  valerian  and  Hoffman's  ether  are  the  remedies,  par  ex- 
cellence, together  with  carbonated  baths  and  resistance  exercises, 
carefully  regulated  diet,  and  observance  of  the  sound  rules  of 
health. 

The  following  cases  taken  from  my  pathological  records  and 
private  practice  illustrate  the  graver  forms  of  the  infrequent  pulse : 

Case  LXI.  Temporarily  Infrequent  Pulse  Due  to  Digitalis. — 
C,  age  forty-four  years.  For  five  years  had  suffered  from  rheuma- 
tism, and  for  eighteen  months  from  dyspnoea  and  palpitation.  One 
week  before  admission  to  hospital  his  feet  began  to  swell,  and  on 
admission  he  was  found  to  be  othopnoeic.  Urine  contained  20  per 
cent,  of  albumin  by  bulk.  After  treatment  by  digitalis,  in  half 
ounce  doses  of  the  infusion,  his  pulse  fell  one  day  to  36,  when  the 
digitalis  was  stopped.  On  the  next  it  had  risen  to  38,  and  three  days 
later  to  54.  Compressed  air  was  then  given  and  pulse  reached  84. 
Subsequently  digitalis  was  given,  but  the  pulse  having  fallen  to  52, 
it  was  stopped.  About  two  and  a  half  months  later  the  patient  died 
from  rupture  of  the  chordae  tendinse  of  the  mitral  valve  (it  was 
thought).  The  aorta  contained  extensive  atheromatous  plates.  The 
heart  weighed  32  ounces.  The  infrequent  pulse  was  ascribed  to  dig- 
italis. 

Case  LXIJ.  Temporarily  Infrequent  Pulse;  Mitral  Stenosis; 
Chronic  Nephritis;  Ascites,  treated  by  Digitalis. — J.,  age  thirty-seven 
years.  Three  years  before  admission  to  hospital  he  began  to  have 
palpitation,  dyspncea.  and  prsecordial  pain,  and  three  months  pre- 
viously, oedema  of  the  feet,  the  urine  being  reduced  to  20  ounces. 


Pulsus  Infrequens  189 

On  examination,  no  radial  pulse  was  found.  Extreme  dyspncea. 
Cough  and  expectoration.  Murmur  in  mitral  area.  Under  the 
infusion  of  digitalis,  in  half  ounce  doses,  improvement  ensued,  but 
after  two  weeks'  use  of  it  the  pulse  began  to  be  infrequent  and  the 
general  condition  worse.  After  the  digitalis  was  stopped,  the  pa- 
tient's condition  improved,  but  the  pulse  becoming  irregular  again 
it  was  resumed,  carbonate  of  ammonia  and  spiritus  frumenti  being 
added  to  each  dose.  The  improvement  in  the  pulse  was  only  tem- 
porary, for  one  month  after  admission  it  had  fallen  to  40.  During 
the  summer  the  patient  was  absent  from  the  hospital,  returning  in 
the  autumn  with  no  radial  pulse,  irregular  cardiac  action,  and  urine 
reduced  to  12  ounces  per  day. 

From  this  second  attack  the  patient  did  not  rally.  At  the  post- 
mortem examination  the  heart  was  found  to  be  fatty,  hypertrophied 
and  dilated,  weighing  22  ounces.  The  mitral  had  a  button-hole 
opening.     There  was  also  chronic  nephritis. 

Case  LXIII.  Temporarily  Infrequent  Pulse;  Mitral  Disease; 
Chronic  Nephritis;  Abdominal  Dropsy. — A  lady  from  Louisville, 
Ky.,  came  under  my  care  in  the  Post-Graduate  Hospital  recently 
with  pulse  64,  temperature  98°,  respiration  24.  She  had  been  under 
pretty  constant  medication  by  digitalis  and  opiates.  During 
her  stay  in  the  hospital  there  was  temporary  suppression  and  subse- 
quently lobar  pneumonia.  On  four  occasions  she  had  attacks  of 
heart  failure,  the  pulse  registering  once  28,  and  three  times  44.  She 
recovered  under  the  use  of  nitrites  and  alcoholics^  with  occasional 
use  of  digitalis  for  diuretic  effects  only.  At  the  time  of  her  return 
to  the  South  the  pulse  had  risen  to  76. 

Case  LXIV.  Mitral  Stenosis;  Phthisis;  Infrequent  Pulse. — In 
still  another  case  of  mitral  disease,  seen  in  consultation,  where  the 
patient  had  suffered  from  haemoptysis  and  had  suppression  and  albu- 
minuria, the  radial  pulse  ranged  from  37  to  40,  and  was  intermittent 
and  irregular.  Though  I  have  learned  that  both  Cases  LXIII  and 
LXIV  are  now  dead,  I  am  not  aware  that  any  post-portem  examin- 
ations were  made. 

The  following  cases  illustrate  lesser  degrees  of  infrequency 
when  the  rate  falls  below  the  standard,  viz.,  60 : 

Case  LXV.  Infrequent  Pulse  in  General  Tuberculosis  and 
Tubercular  Meningitis.^ — S.,  age  nineteen  years ;  stable  boy.  Six 
months  before  admission  to  hospital  he  had  caught  cold,  as  he  ex- 
pressed it,  and  later  had  lost  25  pounds.  He  complained 
of  pain  in  head  and  a  stiff  neck.     Pulse  42,  temperature  100°,  respi- 


190  Pulsus  Infrequens 

ration  20.  Dry  tongue,  scowling-  brow,  ahtlonicn  retracted.  Al- 
buminuria. After  five  months'  stay  in  hospital  he  suddenly 
became  delirious.  Pulse  weak,  32.  A  month  later,  with  tempera- 
ture 99.5°  and  respiration  24,  the  pulse  had  risen  to  64;  but  after 
another  month  it  had  fallen  to  52.  About  a  year  later  the  tempera- 
ture became  subnormal  (97.5°),  respiration  24,  pulse  60.  At  the 
post-mortem  examination  tubercular  pericarditis  was  found.  In 
the  lungs,  liver  and  kidneys,  and  at  the  base  of  brain  miliary  tuber- 
cles.     Cerebral  ventricles  distended  with  serum. 

Case  LXVI.  Melancholia;  Temporarily  hifrcqncnt  Pulse. — 
Z..  a  \oung  man,  listless  and  feeble,  complaining  of  pain  about  the 
head,  spine  and  chest,  with  a  previous  history  of  glycosuria,  un- 
able to  apply  himself  to  any  intellectual  work,  was  under  my  care 
in  1898-99.  Lateral  curvature  with  protrusion  of  right  scapula. 
]\risshapen  head,  marked  difference  between  the  lateral  halves.  Left 
exophthalmos.  Pulse  60  to  64.  Under  treatment  by  carbonated 
baths  and  exercises  the  pain  in  the  back  disappeared  and  the  pulse 
became  more  frequent,  so  that  from  an  average  of  60  it  reached 
J 2.  After  leaving  my  care  for  the  summer  the  patient  relapsed  into 
his  former  condition,  but  after  a  second  course  of  treatment  the  pain 
in  the  head  disappeared  and  the  pulse  again  improved.  The  in- 
frequent pulse  was  attributed  to  his  neurotic  condition,  the  symp- 
toms being  those  of  chronic  basilar  meningitis. 

Case  LXVII.  Mitral  Stenosis;  Periodically  Infrequent  Pulse. 
— In  August,  1899,  I  had  ufider  my  care  a  patient  who  came  to  me 
suffering  from  precordial  oppression,  dyspnoea,  and  a  dilated  heart, 
with  feeble  impulse,  weak  and  irregular  action,  rate  52.  Presystolic 
murmurs  over  the  mitral  area,  not  conveyed.  Occasional  thrill. 
After  treatment  by  carbonated  baths  and  resistance  exercises,  to- 
gether with  strychnine,  his  pulse  rose  to  the  normal ;  his  heart 
nearly  regained  its  normal  dimensions,  and  there  was  absence  of 
prsecordial  pain  and  dyspnoea;  and  the  patient  led  an  active  life 
as  the  member  of  a  very  prominent  firm  in  this  city  for  a  number  of 
years.     His  pulse  rate  was  60  to  64. 

Case  LXVI II.  Infrequent  Pulse  in  Urcemia  in  Association  with 
Diabetes  and  Mitral  Disease  ;Temporarily  Infrequent  Pulse.^A  lady 
of  middle  age,  the  wife  of  one  of  our  most  distinguished  practi- 
tioners, was  placed  under  my  care  some  years  ago.  As  a  child  she 
had  suffered  from  inflammatory  rheumatism,  and  later  from  sciatica, 
getting  relief  from  atropine  and  morphine.  When  first  seen  she  had 
albuminuria  ;  sugar  in  large  amount  and  some  suppression.     Vertigo, 


Pulsus  Infrequens  191 

pain  alternating  between  the  occiput  and  vertex ;  dyspnoea.  Pulse 
56,  intermittent.  Heart's  sounds  almost  inaudible,  but  after  rajnd 
motion  about  the  room  a  slight  murmur,  conveyed  to  the  left,  was 
detected. 

The  uraemia,  and  with  it  the  infrequent  pulse,  was  in  this  in- 
stance promptly  overcome  by  the  use  of  the  muriate  of  pilocarpine 
combined  with  alcoholics.  According  to  my  experience,  this  drug 
may  be  given  in  divided  doses  up  to  as  much  as  one  or  even  two 
grains  per  day,  if  guarded  by  alcoholics  and  watched  by  a  competent 
nurse. 

In  the  following  case  the  infrequent  pulse  has  a  chronic  char- 
acter : 

Case  LXIX.  Arteriosclerosis;  Apoplectiform  Attacks;  Lith- 
<emia;  Infrequent  Pulse,  at  First  Periodic  and  Later  Chronic. — A  pa- 
tient in  middle  life  came  under  my  observation  in  consultation  many 
times  in  the  April  of  190 1.  In  the  preceding  month  he  had  had  an 
apoplectiform  atack,  followed  by  stiffness  in  his  knees  and  hips, 
and  a  sense  of  general  lassitude.  The  usual  local  applications  were 
made ;  in  addition,  he  took  20  grains  of  aspirin  four  times  a  day,  and 
in  a  few  days  was  relieved  of  his  pains.  Muscular  inability  of  the 
left  masseter  remaining,  he  took  salophen  in  20-grain  doses  every 
three  hours,  but  was  obliged  to  return  to  aspirin  for  relief  of  pain. 
At  this  time  the  pulse  had  fallen  to  50.  When  I  first  saw  him  he 
was  taking  morphine  in  small  quantities,  as  he  had  used  it. previously 
for  rheumatic  attacks.  I  immediately  stopped  this  drug,  putting 
him  on  one-fortieth  grain  doses  of  sulphate  of  strychnine,  together 
with  half-ounce  doses  of  v/hiskey  every  four  hours,  and  a  liquid 
diet.  Pulse  was  40,  but  full  and  regular,  synchronous  wath  the 
heart.  Respiration  22  to  24.  Under  this  treatment  the  pulse  had 
risen,  on  May  5th,  to  60.  Digestive  disturbance  causing  intermit- 
tence  of  the  pulse,  strychnine  was  diminished  and  caft'eine  in  one- 
grain  doses  with  asafoetida,  three  grains,  substituted ;  while  occasional 
doses  of  nitro-glycerine  one  one-hundredth  of  a  grain,  were  added. 
Under  this  treatment  the  pulse  continued  to  rise,  so  that  on  May  6th 
it  was  68.  As  it  was  deficient  in  force,  however,  digitaline  (Merck) 
was  given  on  one  occasion  four  times  during  the  day,  nitro-glycerine 
being  substituted  for  it  in  doses  of  one  one-hundredth  of  a  grain 
every  fifteen  minutes,  wherever  necessary.  During  all  this  time 
about  two  and  one-half  ounces  of  whiskey  were  being  given  daily, 
and  after  this  nitro-glycerine  and  strychnine  as  required,  with  w^his- 
key,  at  intervals  of  about  three  hours.      On  Mav  loth,  without  ob- 


192  Pulsus  Infrequens 

xnons  reason,  the  pulse  had  again  fallen  to  about  42,  but  as  it  had 
force  and  regailarity,  no  effort  was  made  to  increase  its  frequency. 
For  about  live  days  it  remained  at  40,  being  strong  and  regular. 
Later,  arsenious  acid  in  one  one-hundredth  grain  doses  and  cactus 
in  the  fluid  extract  form,  in  one  minim  doses,  were  given,  the  pulse 
gradually  rising  under  them  to  60.  On  May  17th  it  had  reached 
70.  The  sulphate  of  quinine  in  eight-grain  doses  and  morphine  in 
one-eighth  grain  doses  for  relief  of  the  pain  replaced  the  arsenic,  but 
the  cactus  was  given  without  interruption,  and  with  no  other  rem- 
edy for  a  week,  when  strychnine  was  again  given.  The  pulse  then 
returned  to  its  normal  frequency  and  so  continued,  although  on  a 
single  occasion  it  fell  to  52.  On  June  26th  the  patient  was  suddenly 
attacked  with  pain  in  his  left  arm  and  wrist,  which  became  swollen 
and  the  pain  recurred  every  morning  for  five  to  six  days.  The 
pulse  fell  to  45.  On  the  morning  of  July  5th  he  was  awakened  with 
buzzing  in  his  ears  and  great  dizziness  ;  no  pulse  at  the  wrist.  Aro- 
matic spirits  of  ammonia,  an  ounce  of  whiskey,  and  a  one-hundredth 
grain  dose  of  nitro-glycerine  were  taken,  and  relief  was  ob- 
tained in  about  half  an  hour.  This  attack,  however,  was  so  pros- 
trating that  the  patient  was  confined  to  his  bed  with  it  until  Sep- 
tember 6th,  the  pulse  ranging  from  35  to  44.  The  treatment  during 
this  time  was  by  strychnine  one-thirtieth  grain,  nitro-glycerine  one 
hundredth,  and  whiskey  one-half  ounce,  taken  every  three  hours. 
Suprarenal  extract  in  three-grain  doses  was  given  for  a  w-eek, 
but  did  not  sustain  the  pulse,  and  was  therefore  abandoned.  Some 
improvement  in  the  pulse,  however,  was  always  noted  after  the  use 
of  the  static  battery.  It  would  rise  to  about  50  on  these  occasions. 
On  the  23d  of  November  the  pulse  reached  60,  when  all  remedies 
except  whiskey  were  suspended.  During  1902  the  pulse  averaged  be- 
tween 48  to  54,  the  remedies  used  being  strychnine,  nitro-glycerine 
and  suprarenal  extract,  increased  to  five  grains,  three  times  a  day. 
In  March  of  1903  I  examined  him,  with  the  following  results : 
Pulse  36  to  44,  of  fair  force  and  regular.  Heart  beats  synchronous 
with  the  pulse.  No  enlargement  of  the  heart.  No  displacement 
of  the  apex ;  no  murmurs,  but  impulse  lacking ;  no  thrill ;  accentua- 
tion of  the  second  sound  at  apex ;  no  palpitation ;  liver  a  little  en- 
larged ;  some  bronchitis.  Physical  condition  good ;  takes  no  reme- 
dies ;  eats  well,  sleeps  well  and  walks  from  one  to  two  miles  a  day 
without  fatigne  or  embarrassment  of  respiration,  but  he  has  the 
facies  arterio-sclerotica.  At  my  last  examination  (1905)  his  pulse 
was  48. 


Pulsus  Infrequens  193 

This  interesting  case  has  now  entered  upon  the  chronic  stage.  By 
some  it  would  be  called  an  instance  of  permanent  bradycardia.  I 
prefer  to  call  it  the  chronic  form  of  the  infrequent  pulse.^'' 

In  September  of  1903  I  saw  two  cases  that  are  worthy  of  note, 
though  I  have  alluded  to  one  of  them.  (Cases  LXX — I.;  In 
the  first,  which  I  saw  in  the  practice  of  Dr.  John  S.  Warren  of 
this  city,  the  patient  had  a  pulse  of  38,  after  an  apoplectiform 
seizure.  In  the  other,  also  already  alluded  to,  the  patient,  after  a 
similar  attack,  of  an  evanescent  character,  had  a  pulse  as  low  as  19, 
with  a  maximum  of  28,  and,  with  his  pulse  at  this  rate,  took  a 
trip  to  Europe.      He  is  now  attending  to  a  rather  active  business. 

"This  history  was  for  the  most  part  prepared  for  me  by  the  patient 
himself. 


Chapter  X\'IT. 

GRAVES'  DISEASE.' 

Graves'  disease  is  characterized  by  a  complex  of  s\niptonis  that 
are  neither  constant  nor  definite,  though  protrusion  of  the  eye-balls, 
enlargement  of  the  thyroid,  a  rapid  and  often  dilated  heart,  and  vari- 
ous neurotic  manifestations  play  the  most  important  roles.  Less  con- 
spicuous parts  are  assumed,  with  varying  degrees  of  frequency,  by 
a  number  of  disorders  whose  relation  to  the  disease  is  not  so  well 
defined ;  the  more  prominent  of  these  being  loss  of  appetite,  emacia- 
tion, diarrhoea,  muscular  weakness,  with  or  without  tuberculosis,  and 
alterations  in  the  texture  and  behavior  of  the  skin. 

It  is  apparent,  therefore,  that  Graves'  disease  may  have  different 
types,  each  of  which,  of  course,  has  different  phases.  The  recogni- 
tion of  these  facts  is  especially  important  in  the  application  of  reme- 
dies, and  it  is  equally  apparent  that  Graves'  disease,  being  partly 
a  functional  and  partly  an  organic  disorder,  offers  great  difficulties 
to  the  nosologist. 

Yet  we  may  safely  and  correctly  speak  of  an  acute,  a  subacute 
and  a  cliroiir  form  ;  or  we  may  distinguish  a  temporary  or  acute 
form  from  an  essential  or  chronic,  though  it  may  not  always  be  pos- 
sible to  draw  sharp  lines  of  distinction  between  them.  But  they  are 
valuable  in  discussing  the  disease  from  a  medical  point  of  view.  On 
the  other  hand,  the  surgical  aspects  of  the  disease  are  best  sub- 
served by  the  recognition  of  a  primary  form,  i.  e.,  where  there  is  a 
tolerably  contemporaneous  development  of  symptoms  sufficiently 
distinctive  to  justify  the  diagnosis  of  Graves'  disease;  and  of  a  sec- 
ondary,  where  equally  characteristic  signs  are  sequels  of  an  old 
goitre. 

As  in  many  other  diseases  of  apparently  recent  discovery  we  have 
only  to  hunt  back  in  the  old  literature  to  find  that  Graves'  disease 
was  described  long  before  the  time  of  Graves  or  Basedow,  or  Fla- 
jani,  whose  names  have  been  tacked  on  to  the  disease  by  English, 
Germans  and  Italians  with  a  zeal  that  has  spoken  much  for  their 
patriotic  instincts,  but  less  for  their  knowledge  of  general  medical 
literature.     We  have  but  to  turn  to  that  treasure-house  of  patholog- 


^If  this  disease  is  to  be  named  after  an  English  physician  it  should  be 
called  Parry's  disease.  At  this  date,  however,  a  change  of  name  might  only 
add  to  the  present  confusion  in  the  nomenclature. 


Graves'  Disease  195 

ical  material,  Morgagni's^  De  Sedibus,  to  find  that  as  early  as  1762 
Morgagni  made  a  post-mortem  on  a  woman  of  40  (of  neurotic  type 
and  delicate  constitution)  who,  without  aijparent  cause,  was  taken 
with  amenorrhoea,  loss  of  appetite  and  ]jalpitation  lasting  for  six 
months,  followed  by  a  sensation  of  fulness  in  the  throat,  difficulty  in 
swallowing,  neuralgias,  especially  of  the  arms,  occasional  spasm  of 
the  masseters,  and  finally  oedema  of  the  right  lower  extremities.  At 
the  post-mortem  examination  he  discovered  an  enlarged  thyroid. 
It  will  be  noted,  in  this  case,  that  he  not  only  detailed  two  out  of 
the  three  cardinal  symptoms,  viz.,  the  enlarged  thyroid  and  palpi- 
tation, but  also  mentioned  a  number  of  lesser  signs,  the  so-called 
"formes  frustes"  described  by  Charcot"  in  1885.  He  failed,  how- 
ever, to  designate  it  as  a  new  disease.  Then,  in  1802,  Flajani*  of 
Rome,  wrote  of  the  connection  between  goitre  and  continuous  pal- 
pitation, and  gave  the  histories  of  three  cases ;  though  no  mention 
was  made  of  exophthalmos  in  any  one  of  them.  Still,  on  the 
strength  of  these  reports,  the  Italians  sometimes  speak  of  Flajani's 
disease.  When,  however,  we  consider  the  work  of  Parry,^  the 
claims  of  all  others  as  to  the  first  satisfactory  elucidation  of  the 
disease,  sink  into  insignificance. 

Parry's  first  statements  were  made  in  1796,  though  his  book 
was  not  published  until  1825.  He  was  the  first  to  enumerate  the 
three  signs,  an  enlarged  thyroid,  hypertrophy  or  palpitation  of  the 
heart,  and  exophthalmos,  known  now  as  the  cardinal  signs  of  the 
afifection,  and  to  state  that  they  were  distinctive  of  a  special  disease, 
which,  as  he  declared,  had  not  previously  been  described.  His  first 
case  (seen  in  1786)  was  of  a  woman  37  years  of  age  who,  while 
in  the  puerperal  state,  had  an  attack  of  rheumatic  fever,  which  w^as 
followed  by  palpitation,  and  three  months  later  by  a  goitre,  ex- 
ophthalmos, loss  of  appetite,  diarrhoea,  night  sweats  and  oedema 
of  the  extremities.  He  detailed  in  all  eight  cases,  and  his  descrip- 
tions covered  nearly  all  of  the  symptoms,  both  major  and  minor, 
such  as  dilatation  of  the  carotids,  dyspnoea,  the  nervous  manifesta- 
tions and  oedema.  In  the  last  seven  there  was  no  exophthalmos, 
and  no  allusion  was  made  to  tremor,  which,  however,  appears  to 
have  been  first  noticed  in  the  eighties  of  the  last  century  (1883), 


'  Morgagni,  Liber  v.  1762. 

^  Charcot,  Des  formes  frustes  de  la  maladie  de  Basedow.  Gas.  des  Hop., 
13,  15,  1885. 

*  Flajani,  Collez.  d'osserv.  e.  riHess,  chir.,  IV,  Roma  1802,  p.  270. 

"  Parry,  Collections  from  Unpublished  Med.  Writings,  London,  1825, 
II  p.  3- 


196  Graves'  Disease 

Graves'*  published  his  celebrated  paper  in  1835.  bui  the  subject 
was  not  elaborated  b\  him  until  1849.  Meanwhile,  others  in  Great 
Britain  had  published  similar  cases.  Graves,  however,  claimed 
that  the  disease  was  a  neurosis  of  the  heart,  or  of  the  vessels  of 
the  neck  ;  thoui^h  of  the  two  varieties  which  he  contra-distinguished, 
one  was  associated  with  heart  disease  and  the  other  was  not. 

But  prior  to  the  final  elaboration  of  this  subject  by  Graves,  Von 
Basedow,'  of  Germany,  had  written  of  the  same  subject,  in  1840, 
and  the  name  Basedow's  disease  is  pretty  generally  applied  to  it 
by  Germans. 

Since  tlie  publication  of  Von  Basedow's  article  attention  has 
been  called  by  Marie''  to  tremor  as  a  sign  of  the  disease,  and  we 
have  discovered  something  since  then  of  its  hereditary  character,  its 
behavior  under  the  galvanic  current,  and  its  relation  to  the  sexual 
apparatus.  We  have  also  learned  much  about  the  thyroid  gland, 
and  especially  that  it  elaborates  a  chemical  substance,  the  failure 
to  excrete  which  produces  myxoedema."  Besides,  we  have  found 
that  in  certain  primary  cases  cure  follows  galvano-puncture  ;  and 
in  some  secondary  cases,  perhaps,  extirpation  by  the  knife. 

Graves'  disease  is  rare.  Flint,  with  his  extensive  practice,  tells  us 
that  he  saw  only  five  cases  in  ten  years.  And  yet  it  is  quite  certain 
that  many  escape  notice,  especially  when  the  enlargement  of  the 
thyroid  is  slight.  Probably  there  are  conditions  of  climate,  locality 
and  habits  of  life  that  determine  it ;  but  this  matter  is  not  clear  at 
the  present  time.  In  twelve  cases  of  which  I  have  notes  there 
was  but  one  male.  It  may  occur  at  almost  any  age,  and  is  rather 
more  common  among  Jews  than  among  other  races.  In  men  it 
comes  in  the  third,  fourth  and  fifth  decades  by  preference ;  in 
women  it  usually  occurs  under  the  age  of  40.  Of  980  cases  col- 
lected by  Buschan  {Die  Basedozvsche  Kraiikheif,  Wien  and  Leip- 
sig,  1894),  805,  or  82  per  cent.,  were  women.  It  is  very  apt  to 
develop  in  persons  of  a  neurotic  type  and  may  be  hereditary.  It 
is  not  at  all  uncommon  to  find  that  it  has  been  produced  by  some 
physical  or  mental  strain,  usually  the  latter.  In  one  of  my  cases 
it  occurred  after  the  first  parturition. 

Case  LXXII.     Graves'    Disease,    Tuberculosis. — M.,    married, 


'Graves,  A  newly  observed  affection;   London  Med.   and  Sur.   Journal, 
May  23,  1835. 

^v.  Basedow,  Exophthalmos.     Caspar's  Wochcnschnft  f.  d.  Gcs.  Heilkde, 
Nos.  13  and  14- 

*  Marie.   Contributions,  etc.      These  de  Pans,   1883. 
'Moebius,  Die  Erkrankungen  der  Schildruse.      Wien,  1896. 


Graves'  Disease  197 

23,  a  resident  of  this  city  came  to  my  clinic  at  the  Post-Graduate, 
complaining  that  she  had  been  losing  flesh,  had  pain  in  the  right 
chest,  cough,  difficult  respiration,  headache  and  loss  of  appetite. 
The  eyes  protruded  slightly;  the  thyroid  was  somewhat  enlarged. 
The  heart's  action,  however,  was  normal,  and  there  were  no  special 
nervous  manifestations.  The  patient  had  noticed  these  symptoms 
of  Graves'  disease  for  about  three  years,  and  they  seemed  to  date 
from  the  first  parturition.  This  patient  was  found  to  have  pulmon- 
ary phthisis  in  the  second  stage. 

From  time  to  time  views  have  been  advanced  that  the  cause 
of  the  disease  lay  in  the  sympathetic,  and  efforts  were  made  to  dis- 
cover special  lesions.  It  is  true  that  degeneration  of  sympathetic 
fibres,  atrophy  of  ganglion  cells,  and  pigmentation  of  both  fibres 
and  cells  have  been  found  by  some  observers  ;  but,  on  the  other 
hand,  others  have  failed  to  fipd  them.  Moreover,  we  have  learned 
that  in  normal  nerve  tissues  these  degenerative  changes  are  going 
on  more  or  less  continuously.  Nor  have  researches  in  the  brain 
and  cord  in  these  cases  been  any  more  successful. 

In  one  case,  however,  Filehne  {Zur.  Path,  der  Bas.  Krankheit ; 
Sit:::.  Ber.  der  Phys.  Med.  Soc.  su  Erlangen,  July  14,  1879)  relates 
that  he  produced  an  exophthalmos,  rapid  action  of  the  heart,  and 
enlargement  of  the  thyroid  by  division  of  the  anterior  fibres  of 
the  restiform  bodies.  But  after  all,  emotional  causes  may 
equally  well  produce  all  these  symptoms.  Evidently,  there  is  one 
constant  condition,  however,  and  this  is  a  vasomotor  paresis — and 
while  it  may  have  an  organic  base,  it  is  just  as  Hkely  to  be  a  func- 
tional disorder,  certainly  at  first. 

Buschan,  in  his  prize  monograph,  accordingly,  divides  Graves' 
disease  into  two  varieties,  (i)  where  there  is  a  genuine  neurosis, 
with  marked  psychic  and  vasomotor  symptoms,  and  (2)  where 
it  is  symptomatic,  i.  e.,  called  into  action  by  peripheral  lesions  of 
the  sympathetic,  as  in  intestinal  disorders,  operations  on  the  nose 
and  teeth,  or  by  reflex  influences  from  the  brain.  It  has  also  been 
maintained  that  thyroid  hypertrophy  is  superinduced  by  an  excess 
of  certain  toxins  which  the  alimentary  canal  generates  in  health, 
but  which  normally  are  neutralized  by  the  action  of  the  gland. 
Being  in  excess,  they  superinduce  a  thyroid  hypertrophy.  Yet 
it  seems  quite  as  reasonable  to  believe  that  the  diseased  thyroid  may 
permit  of  the  development  of  the  toxins  by  withholding  certain  mat- 
ters necessary  to  their  destruction. 

Graves'  disease  is  slow  in  developing.      It  is  said  that  the  onset 


iq8  Graves'  Disease 

is  accompanied  witli  tremors.  Of  this  I  have  no  personal  knowl- 
edg;e.  Tremors  are  often  noticeable,  however,  after  the  disease  is 
recognizable  in  the  thyroid.  They  are  like  those  of  paralysis  agi- 
tans  or  chorea,  but  more  rapid.  Headaches  are  common,  and  sweat- 
ing may  be  profuse  during  the  acute  stage,  even  when  there  is  no 
tuberculosis,  which  later  is  common,  in  my  experience.  The  poly- 
uria or  glycosuria,  discoloration  of  the  skin,  artificial  urticaria,  ex- 
aggerated reflexes,  affections  of  phonation,  numbness  of  the  limbs, 
sleeplessness,  irritability,  confusion  of  ideas,  melancholy,  or  even 
more  serious  diseases,  are  further  evidences  of  the  neurotic  nature 
of  this  disease.  Epilepsy  has  sometimes  been  observed,  but  it  must 
be  remembered  that  some  of  these  nervous  manifestations  may  be 
fruits  of  the  same  neurotic  tree — associated  affections  and  yet  not 
parts  and  parcels  of  the  disease. 

In  one  of  my  cases  there  was  facial  spasm,  but  whether  an  in- 
trinsic symptom  or  an  associated  one,  I  do  not  know.  It  appeared 
long  before  there  was  any  noteworthy  sign  of  thyroid  enlargement. 

Case  LXXIII.  Graves'  Disease;  Thyroid  E)ilargcment  ef- 
fectually Treated  by  Galvano-puncture . — F.,  44,  unmarried,  a  neu- 
rotic subject,  has  been  under  my  observation  more  or  less  for  a 
period  of  27  years,  during  all  of  which  time  she  has  had  cardiac 
disease.  Twenty-five  years  ago  she  began  to  have  attacks  of  heart 
failure,  and  has  had  them  at  intervals  ever  since.  Mitral  stenosis, 
cardiac  dilatation.  Has  also  had  enlarged  venous  radicles  in  lower 
extremities,  with  at  times  ecchymoses.  During  all  this  time  has 
had  hemifacial  spasm  and  atrophy. 

Exophthalmos  and  enlarged  thyroid  developed  at  a  time  she 
was  not  under  my  care,  but  without  tremor,  and  without  tachy- 
cardia. The  gland  was  practicall}-  reduced  to  tlie  normal  size  by 
galvano-puncture  (Professor  Emmet).  .Since  that  time  the  ex- 
ophthalmos has  disappeared,  and  under  aconite,  suprarenal  extract 
and  nitroglycerine  taken  for  occasional  attacks  of  heart  failure,  she 
has  done  fairly  well.  For  the  past  eighteen  months,  I  understand, 
she  has  had  no  medical  treatment  whatever. 

Hyperaesthesia,  hemianesthesia  and  par?esthesia  have  all  been 
noted.  Among  the  trophic  symptoms  come  pigmentation  of  the 
skin,  especially  bronze  discoloration  about  the  eyes,  or  on  scattered 
parts  of  the  body.  Sometimes  they  look  like  spots  of  sunl)urn,  in 
other  cases  the  skin  is  as  dark  as  in  a  mulatto. 

The  following  case  is  an  example  of  this  discoloration : 

Case  LXXIV.     Graves'   Disease;   E/^ilepfifonn   Seizures;    Uni- 


Graves'  Disease  199 

lateral  Pigmentation  of  the  Skin;  Malarial  Fever;  Cardial  Dilata- 
tion; Tremor. — F.,  23,  unmarried,  consulted  me  in  March,  1901. 
For  a  year  she  had  been  complaining  of  [jraicordial  pain,  palpitation 
and  headache,  with  dysmenorrhcea,  irritable  bladder,  migraine  and 
constipation.  From  childhood  had  attacks  of  unconsciousness, 
when  her  face  was  suffused,  feet  and  hands  were  cold,  and  she 
was  rigid.  Her  attacks  lasted  about  half  an  hour.  The  next 
day  she  was  very  stupid  and  prostrated.  .She  also  had  occasional 
attacks  of  malarial  fever.  Upon  examination  the  apex  was  found 
to  be  under  the  left  nipple.  The  pulse  was  inclined  to  be  rapid 
and  irregular.  Unilateral  pigmentation  of  the  skin  of  the  right 
side  of  the  face.  Membranous  vaginitis,  tremor,  moderate  en- 
largement of  the  thyroid.  No  exophthalmos.  After  treatment  ap- 
plicable to  her  malaria  and  constipation,  her  neurotic  condition, 
malaria  and  dysmenorrhcea,  she  gradually  improved,  so  that  on  Oc- 
tober 28th  of  the  same  year  her  mother  reported  that  she  was 
"quite  well."  Hysteria  in  most  of  its  manifestations  may  add  a 
further  complication,  and  probably  did  in  this  instance.  She  had 
also  at  time  the  sudden  "giving  way  of  the  legs,"  the  para-paresis 
described  by  Charcot.  She  would  at  times  feel  a  gradual  dim- 
inution of  power,  and  then  her  lower  limbs  would  suddenly  give 
way  altogether. 

The  skin  may  be  red  or  pale,  abnormally  dry  or  abnormally  wet. 
There  is  a  form  of  erythema  that  is  common  on  the  face,  usually 
in  the  form  of  spots,  though  pigmentation  is  more  common.  The 
dark  areas  may  be  diffuse  or  in  spots,  as  around  about  the  eyes 
or  the  nipples,  on  the  neck,  in  the  arm  pits,  on  the  abdomen,  or  in 
any  location  there  is  pressure,  as  imder  the  garters.  The  mucous 
membrane  is  rarely  discolored.  The  nails  are  free.  The  face  is 
most  affected.  The  patients  also  flush  easily,  and  mechanical  fric- 
tion causes  a  dilatation  of  the  capillaries  which  persists  for  a  con- 
siderable  time. 

One  of  the  first  signs  to  w^hich  the  attention  is  called  is  palpita- 
tion. The  arteries,  veins  and  capillaries  become  gradually  soft 
and  dilated,  especially  those  of  the  neck ;  there  may  also  be  throb- 
bing of  the  abdominal  aorta.  The  signs  of  cardiac  dilatation  are 
not  evident  at  first,  but  they  set  in  early.  The  murmurs,  in  the 
absence  of  valvular  disease,  are  usually  heard  at  the  base,  and 
the  cause  may  be  the  prevailing  anaemia.  When  dilatation  is  es- 
tablished, the  apex  beat  will  be  diffuse.  As  the  disease  advances 
there  may  be  some  irregularity  in  its  action.  In  severe  cases,  or  in 
the  final  stage,  there  mav  even  be  delirium  cordis.     I  have  seen  one 


200  Graves'  Disease 

case  (Case  LXX\")  where  the  jhiIsc  was  so  rapid  that  it  could  not  be 
counted,  but  complete  recovery  took  place. 

Case  LXXr.  Acute  Uraics'  Disease;  Frequent  Pulse;  Recov- 
ery.— Mrs.  X.  was  seen  by  me  in  consultation  with  two  other  physi- 
cians in  February.  1807.  ^be  had  previously  exhausted  about  all 
known  rcnicilios,  and  had  consulted  many  eminent  medical  men. 
She  was  confined  to  bed,  and  was  in  a  hii^^hly  hysterical  condition, 
crying,  wrniging  her  hands  and  complaining  of  a  "flutter"  or 
""twitching"  about  her  lieart.  Skin  bathed  in  sweat.  Pulse  too 
rapid  to  count.  Stomach  distended  with  gas.  which  she  belched 
at  intervals.  Xausea  and  at  times  vomiting.  Great  praecordial 
distress,  but  respiration  normal.  Xo  exophthalmos,  but  enlarged 
thyroid  and  tachycardia.  Epigastric  pulsation.  Pseudo-angina. 
Attacks  of  this  kind  she  was  subject  to,  and  they  had  reduced  her 
75  pounds  weight  in  two  years,  although  she  was  still  corpu- 
lent. Xo  cardiac  murmurs,  but  apex  5^^  inches  from  the  median 
line.  Xo  cyanosis.  Under  treatment  by  diet,  laxatives,  stomachics 
and  resistance  exercises  there  was  general  improvement,  the  pulse 
falling  to  66.  Eventually  there  was  a  complete  recovery,  I  was 
told,  by  one  of  her  physicians. 

The  thyroid  may  be  uniformly  enlarged,  or  only  in  one  lobe. 
In  a  small  number  of  cases,  which  some  have  estimated  at  about 
8  per  cent.,  it  will  not  be  involved  at  all.  On  this  point  there  is 
a  pretty  general  agreement.  As  a  rule,  enlargement  of  the  gland 
follows  the  palpitation,  but  the  swelling  may  come  and  go.  Usu- 
ally the  dilatation  of  the  veins  is  well  seen  in  those  coursing  over 
the  gland.  There  may  even  be  heard  a  blowing  murmur  over  the 
gland  from  its  dilated  vessels.  Various  changes  may  take  place  in 
it.  At  first  it  is  apt  to  be  soft  and  yielding ;  later  induration  may 
set  in.  or  it  may  become  cystic.  The  enlargement  may  get  to  be  so 
great,  especially  when  cysts  develop,  that  deglutition,  phonation 
and  respiration  are  interfered  with. 

•  The  diagnosis  of  implication  of  the  thyroid  is  made  with  un- 
erring accuracy,  as  we  all  know,  by  noting  that  the  tumor  goes  up 
and  down  with  every  attempt  to  swallow. 

As  a  rule,  in  point  of  time  the  exophthalmos  follows  the  goitre. 
It  varies  in  degree,  and  usually  involves  both  eyes.  In  extreme 
cases  the  protrusion  of  the  eyes  may  be  so  great  as  to  prevent 
closure  of  the  lids  and  make  glasses  necessary  as  a  protection  for 
the  eye-balls.  In  these  cases  there  may  be  the  Von  Graefe  symp- 
tom, where  there  is  inability  of  the  lid  to   follow  the  downward 


Graves'  Disease  201 

movement  of  the  eye,  or  the  Stellwag  symptom,  of  actual  retraction 
of  the  upper  Hd.  A  moderate  swelling-  of  the  lymphatic  glands  has 
been  noticed,  also  an  enlargement  of  the  sjjleen. 

A  symptom  which  should  not  be  omitted  is  the  anaemia  which 
is  quite  frequent.  In  some  cases  independent  of  renal  diseases 
which  are  late  occurrences,  it  may  lead  to  local  oedema.  In  one  of 
my  patients  oedema  of  the  upper  lids  was  a  very  marked  symptom, 
and  lasted  for  years. 

In  women  menstruation  is  usually  normal.  But  sometimes  at- 
rophy of  the  sexual  organs,  bilateral  or  unilateral,  has  been  ob- 
served, with  falling  out  of  hair  and  atrophy  of  the  mammae.  On 
the  other  hand,  there  may  be  unusual  development  of  the  breasts. 
There  is  usually  no  implication  of  the  kidneys,  bones  or  joints. 
Diarrhoea  is  not  uncommon.  It  comes  on  without  apparent  cause, 
and  is  usually  painless.      In  other  cases  there  is  constipation. 

One  form  of  the  glycosuria  has  been  called  alimentary,  because 
it  will  disappear  when  the  carbohydrates  are  eliminated.  On  the 
other  hand,  there  is  a  form  of  glycosuria  that  is  not  affected  by 
the  diet.     In  any  event  it  is  not  a  prominent  symptom. 

So  far  as  the  diagnosis  is  concerned  there  is  no  difficulty  when 
any  two  of  the  three  cardinal  signs,  palpitation,  goitre  and  ex- 
ophthalmos are  present ;  but  in  the  absence  of  two  of  them,  when 
the  minor  manifestations  have  to  be  taken  into  consideration,  there 
may  be  great  difficulty  m  reaching  a  satisfactory  diagnosis.  Be- 
sides these  atypical  forms,  we  have  to  reckon  with  abortive  cases. 
When,  however,  we  find  a  patient  of  neurotic  disposition  that  has 
one  of  the  cardinal  signs,  associated  with  symptoms  of  tre- 
mor, alterations  in  the  character  and  behavior  of  the  skin,  hy- 
persesthesia  or  parsesthesia,  the  diagnosis  can  be  made  with  a  rea- 
sonable amount  of  safety. 

The  course  of  the  disease  is  variable,  but  is  usually  slow.  Acute 
cases  have  been  known  to  get  well  in  a  couple  of  weeks,  and  yet 
■death  may  occur  in  six  weeks.  The  average  duration  of  chronic 
cases  is  five  to  ten  years.  Cases  which  take  long  to  develop  are 
less  dangerous  to  life ;  but  if  the  strength  fails  rapidly,  vomiting 
is  persistent,  and  the  heart  action  becomes  irregular,  the  outlook 
is  unfavorable.  The  chief  points  bearing  on  the  prognosis  are 
the  action  of  the  heart  and  the  emaciation.  If  the  frequency  of 
the  pulse  diminishes  and  the  patient  puts  on  flesh,  the  outlook  is 
■encouraging.      Violent  pulsation,   vomiting,   diarrhoea,   diseases   of 


202  Graves'  Disease 

the  cornea,  paralysis,  mental  disturbances,  are  of  bad  omen 
(Buschan).  The  disease  is  more  violent  in  men  than  in  women. 
The  prognosis  is  not  affected  by  age  except  that  in  advanced  life 
there  is  less  capacity  for  resistance.  If  with  failing  heart  there  is 
renal  inadequacy  with  albuminuria  and  dropsy,  the  prognosis  is  bad ; 
so  also  in  cases  complicated  by  phthisis. 

According  to  \'.  Graefe,^"  complete  cure  takes  place  in  25  per 
cent. ;  considerable  improvement  in  about  50  per  cent.  About 
12  per  cent,  die  of  the  disease.  There  is  hope,  however,  even 
in  the  worst  cases.  When  the  exophthalmos  and  goitre  are  pro- 
nounced, the  prognosis  is  naturally  more  unfavorable.  Though  I 
know  of  no  spontaneous  cures,  they  are,  I  think,  w'ithin  the  bounds 
of  possibility. 

Failure  to  treat  this  disease  successfully  has  been  largely  due  to 
misconceptions  of  its  nature,  and  consequently  to  the  use  of  the 
most  inappropriate  remedies.  There  is  no  standard  treatment 
suitable  for  every  case.  Each  must  be  a  law  unto  itself,  remedies 
being  so  applied  as  to  control  the  particular  elements  that  are  con- 
spicuously offensive.  Therefore,  while  iodine,  iron,  arsenic  and 
various  other  drugs,  hydrotherapy,  electricity,  electro-puncture  and 
operative  procedures  all  have  their  uses,  they  are  only  to  be  em- 
ployed in  distinct  types  or  phases  of  the  disease.  There  can  be  no 
doubt  that  on  account  of  the  recognition  of  this  principle  we  are 
more  successful  than  formerly  in  our  treatment. 

Assuming  that  we  are  called  upon  to  treat  one  of  the  primary 
or  genuine  types,  where  the  neurotic  signs,  the  cardiac  disturb- 
ance, the  enlarged  thyroid,  and  the  exophthalmos  are  in  evidence, 
and  there  is  nothing  apparent  to  account  for  it,  rest  should  be  en- 
joined, with  separation  from  the  family,  and  all  sources  of  excite- 
ment or  nerve  strain  prohibited.  It  may  perhaps  be  imperative 
to  send  the  patient  at  once  to  some  quiet  resort,  where  there  can 
be  no  worry  or  cause  of  excitement.  Under  such  circumstances 
some  form  of  the  Weir-Mitchell  treatment  is  useful.  If  the  pulse 
happens  to  be  very  rapid,  the  patient  should  be  kept  in  bed  :  but 
under  no  circumstances  should  drugs  like  digitalis  or  its  congeners, 
or  veratrine,  be  given  to  lower  the  action  of  the  heart.  The  heart, 
on  the  contrary,  needs  to  be  soothed,  and  bromides,  camphor,  va- 
lerian or  asafcetida  are  indicated. 

Coffee,  tea  and  tobacco  must  be  interdicted.      As  soon  as  the 

'"v.   Graefe,  Dcutsch.   Klinik.,   1864,   s.   158. 


Graves'  Disease  203 

pulse  has  fallen  measurably,  hydrotherapy  is  important  and  car- 
bonated baths  are  useful.  Acute  cases,  however,  should  certainly 
not  be  sent  to  the  baths  of  Nauheim,  Homburg,  Franzensbad,  or 
Pyrmont.  The  artificial  method  as  practiced  in  this  city  is  more 
appropriate.  After  such  a  course,  the  patient  may  make  a  tour 
to  the  mountains,  Saratoga  or  the  Adirondacks,  or  if  abroad,  to 
the  Carpathians,  Tyrol,  Switzerland,  or  Scotland,  not  going  to  an 
altitude  of  more  than  fifteen  hundred  feet.  In  acute  cases  cold 
applications  to  the  heart  may  give  relief.  In  the  subacute  stage 
electricity,  galvanism,  faradism  or  the  static  current  are  helpful. 
Such  applications  appear  sometimes  to  cause  a  fall  in  the  pulse  and 
control  the  tremor. 

In  using  the  galvanic  or  faradic  current,  one  pole  should  be 
applied  to  the  angle  of  the  jaw  and  the  other  to  the  episternal 
notch,  in  order  to  reach  the  sympathetic  of  the  neck.  For  the  spine, 
one  pole  should  be  applied  over  the  fifth  dorsal  vertebra  and  the  other 
over  the  gland.  The  patient  should  understand  that  he  must  not 
expect  improvement  until  months  have  elapsed.  The  current 
should  be  weak,  and  only  applied  daily,  or  two  or  three  times  a 
week,   for  one  minute. 

The  drugs  that  have  been  used  are  numerous.  It  is  safe  to 
say  that  so  far  as  reducing  the  number  of  pulsations  are  con- 
cerned, drugs  are  practically  inert,  and  that  veratrine  especially 
is  inadvisable.  But  if  the  palpitation  and  frequent  pulse  are  to 
be  reduced  by  drugs,  first  in  order  come  the  bromides,  with  cam- 
phor, aconite  and  nux  vomica.  Belladonna  is  useful,  especially 
in  the  form  of  plasters.  Where  there  is  chlorosis,  iron  and  arsenic 
are  useful.  Iodine  is  also  of  value.  Theoretically,  so  far  as  its 
action  on  the  vessels  is  concerned,  it  is  harmful,  as  it  causes  vaso- 
dilatation and  so  accentuates  the  disease.  In  syphilitic  cases,  how- 
ever, it  may  be  of  considerable  service.  Nitrites,  so  far  as  they 
are  vasodilators,  are  not  indicated,  but  ergot,  strychnine  and  cactus, 
being  vasoconstrictors,  may  be  useful. 

So  far  as  the  use  of  thyroid  extract  is  concerned,  recovery 
took  place  in  one  of  my  cases,  which  I  saw  in  the  acute  stage,  under 
the  use  of  this  agent,  the  thyroid  extract,  given  in  five  grain  doses 
three  times  a  day,  but  it  took  about  two  years.  Another  case,  how- 
ever, seen  by  my  colleague,  a  surgeon,  who  saw  the  first  case  with 
me,  was  not  benefited  by  the  treatment  and  died  within  a  year. 
My  patient  had  such  a  large  goitre  that  it  produced  dyspnoea,  the 
palpitation  was  marked,  and  there  were  nervous  symptoms  as  well. 


204  Graves'  Disease 

Surgical  interference  seemed  to  be  imminent,  and  yet  under  the 
thvroid  treatment  he  was  entirely  cured. 

The  following  are  the  notes  of  this  case: 

Case  LXXVl.  Acntc  Graves'  Disease;  Treatment  by  Thyroid 
Extract ;  Recovery. — In  the  summer  of  1896  I  was  asked  to  see  the 
following  case  with  Dr.  Heffinger,  of  Portsmouth,  New  Hampshire: 
J.  F.  R..  32.  a  mason,  after  some  family  misfortune  that  weighed 
heavily  on  him.  found  that  he  had  so  large  a  thyroid  that 
it  interfered  with  his  swallowing.  When  seen  by  me  he  was 
intensely  nervous,  and  had  a  frequent  pulse.  Between  the  skin 
and  the  thyroid  was  also  a  smaller  tumor,  about  the  size  of  a  robin's 
egg,  which  was  plainly  cystic,  and  entirely  disconnected  with  the 
thyroid.  1  advised  aspiration  of  the  smaller  tumor,  the  inter- 
nal use  of  the  iodide  of  potassium,  external  use  of  lead  ointment,  in- 
jections of  Lugol's  solution,  and,  these  failing,  thyroid  extract.  The 
man  then  passed  from  under  my  observation,  but  two  years  later  pre- 
sented himself  to  me.  The  thyroid  enlargement  had  disappeared, 
and  with  it  the  frequent  pulse,  and  his  other  nervous  symptoms ; 
but  the  little  cystic  tumor  still  remained,  apparently  of  about  the 
same  size.  It  appeared  that,  under  the  directions  of  his 
physician,  he  took  the  thyroid  extract  in  5  grain  doses  three 
times  a  claw  but  there  was  no  positive  improvement  until  he  had 
persevered  for  about  six  months.  Then  he  noticed  a  diminution 
in  the  gland.  The  thyroid  extract  was  accordingly  continued. 
Symptoms  of  thyroidism  would  occasionally  be  manifested,  when 
the  remedy  would  be  intermitted,  to  be  resumed  again  when  these 
symptoms  had  disappeared. 

Since  1898  he  has  had  no  occasion  to  take  the  extract,  and  I 
learned  in  1903  that  he  regarded  himself  as  well.  Dr.  R.  Abra- 
hams of  this  city  has  called  my  attention  to  a  record  of  three  cases 
treated  by  him,  one  by  mercurial  inunction  and  two  by  saturated 
solutions  of  the  iodides  {Phil.  Med.  Jour.,  Feb.  9,  1901).  Appar- 
ently all  of  the  three  cases  developed  after  syphilitic  infection,  and 
were  cured  by  anti-syphilitic  remedies,  in  periods  ranging  from 
six  to  ten  weeks.  This  is  another  illustration  of  what  medicines 
may  do  in  such  conditions. 

On  the  other  hand,  Moebius  and  others  claim  to  have  had 
success  by  feeding  their  patients  exclusively  on  the  milk  of  goats, 
whose  thyroids  had  been  removed.  The  theory  of  this  treatment 
was  that  these  animals  might  develop  in  their  systems  a  substance 


Graves*  Disease  205 

that  would  neutralize  the  toxins  of  the  patients.  It  is  said  that  the 
results  were  encouraging. 

Personally,  I  have  tried  injections  of  iodine  and  alcohol  without 
avail.  And  in  one  of  my  cases  where  partial  extirpation  had  been 
practiced  in  Vienna,  the  general  symptoms  were  not  relieved,  though 
the  gland  was  diminished.  The  following  is  a  case  treated  by  me 
in  the  earlier  years  of  my  practice,  and  without  success : 

Case  LXXVII.  Chronic  Graves'  Disease,  with  Special  Neu- 
rotic Manifestations. — Mrs.  S.  consulted  me  on  February  8,  1876. 
There  was  marked  exophthalmos ;  great  enlargement  of  the  thy- 
roid, palpitation  and  nervous  excitement.  Great  difficulty  in  breath- 
ing and  articulating,  a  sensation  as  if  "the  throat  were  swollen 
on  the  inside,"  loss  of  power  and  numbness  in  hands  and  arms,  con- 
fusion of  ideas.  On  May  29th  of  the  same  year  the  tumor  had 
diminished  a  little,  but  on  February  21,  1877,  the  condition  had 
not  improved.  On  September  9,  1878,  when  I  last  heard  from  her, 
she  expressed  herself  as  no  better.  Palpitation  had  continued.  She 
also  had  "pounding"  in  her  head  at  night,  and  had  lost  weight. 
Digitalis  had  been  given  her  (but  not  by  me,  of  course)  without 
any  good  effect. 

In  the  twelve  cases  of  which  I  have  notes^  it  is  noteworthy 
that  five  of  them  exhibited  signs  of  pulmonary  tuberculosis,  and 
two  oedema  of  the  extremities. 

Relief  follows  surgical  treatment  also.  Extirpation,  partial  or 
complete,  is  justified  in  extreme  cases,  without  doubt,  when  other 
methods  have  failed,  and  there  is  no  cachexia  or  cardiac  weakness. 
Heydenreich^^  has  reported  on  61  cases  of  removal  of  the  gland. 

There  were  50  cures  or  improvements  and  4  deaths  and  5  fail- 
ures. Tetanus  developed  twice.  Buschan,  in  116  cases,  reported 
as  results  23  deaths  (22  per  cent.),  45  improved,  3  unchanged,  45 
uncertain.  In  Heydenreich's  cases,  however,  it  has  been  claimed 
that  most  of  them  were  old  goitres  to  which  the  other  symptoms 
had  attached  themselves  later,  i.  e.,  they  were  cases  of  secondary 
exophthalmic  goitre.  In  primary  cases  it  may  be  a  success,  but 
how  much  of  a  success  is  not  certain.  In  these,  too,  there  may  be 
failure  and  death,  the  result  of  the  operation.  This  operation  is 
always  a  serions  one. 

Jonnesco  {Internat.  Clinics,  Vol.  i,  1903),  of  Bucharest,  has 
claimed    that    bilateral    sympathectomy    of    the    cervical    sympa- 


Heydenreich,  Semaine  Med.,  XV.  32,  1895. 


2o6  Graves'  Disease 

thetic  will  relieve  the  symptoms  in  a  majority  of  the  cases.  In  a 
demonstration  made  by  him  at  his  clinic  in  Bucharest  he  showed 
three  cases  that  had  been  operated  on  during-  the  previous  five  years 
and  claimed  that  the  relief  was  lasting.  In  all,  the  size  of  the 
goitre  had  notably  diminished  and  the  frequent  pulse,  the  tremor 
and  exophthalmos ;  and  he  thought  the  effect  produced  was  better 
than  in  ablation  of  the  thyroid  gland,  partial  or  complete,  an  opera- 
tion that  he  regarded  as  both  dangerous  and  not  to  be  depended 
on.  In  his  operation  he  extirpated  the  lowest  ganglion  of  the  cer- 
vical sympathetic.  From  his  report,  however,  the  results  were  far 
from  satisfactory.  The  symptoms  had  diminished,  but  had  not 
disappeared. 


CllAPTIiR    XV  111. 

ANGINA    PECTORIS.^ 

Looking  at  the  matter  broadly,  angina  pectoris  is  for  the  present 
the  most  convenient  name  for  a  small  group  of  affections  in  which 
the  predominant  feature  is  an  intense  pain  over  the  prsecordial  re- 
gion, occurring  in  paroxysmal  attacks,  never  prolonged  so  as  to 
become  chronic,  and  in  some  severe  instances  associated  with  the 
subjective  symptoms  of  impending  death.  The  pain  may  radiate 
from  the  prsecordial  region  in  various  directions  and  to  various 
distances,  often  to  the  left  arm.  Sometimes  it  will  originate  at  a 
distant  part  and  fly  to  the  heart. 

Affections  of  the  coronary  system  are  conspicuous  among  the 
pathological  findings,  while  degenerative  changes  in  the  ascending 
aorta,  aortic  endocarditis,  myocardial  disease  and  general  arterio- 
sclerosis are  found  with  varying  degrees  of  frequency.  No  one  of 
the  lesions,  however,  is  absolutely  constant. 

The  term  angina  pectoris  depicts  a  characteristic  symptom  of 
these  affections,  has  served  us  well  for  over  a  hundred  years,  and 
involves  no  unproved  theories.  We  retain  it  as  we  have  retained 
the  term  epilepsy,  which  does  not  describe  the  essence  of  the  dis- 
ease, but  merely  a  symptom.  It  is  sometimes  better  to  "bear  those 
ills  we  have,  than  fly  to  others  that  we  know  not  of." 

Fortunately,  the  name  does  not  lead  us  astray.  It  includes 
a  perfectly  well  known  class  of  cases  for  which  we  institute  reme- 
dial measures,  in  the  way  of  prophylaxis  and  treatment,  that  relieve 
and  often  cure. 

Angina  pectoris  was  certainly  known  as  early  as  the  time  of 
Morgagni,"^  who  gave  the  clinical  history  of  a  case  occurring  in 
his  individual  experience  and  the  post-mortem  features,  which  in- 
cluded atheroma  of  the  aorta,  disease  of  the  aortic  valves,  coronary 
arteries,  myocardium,  and  general  arteriosclerosis. 

A  few  years  later  Lorry  saw  a  similar  case  in  a  captain  of 
cavalry  at  Besancon,  and  the  letter  describing  it,  according  to 
Peter, ^  was  dated  February  23,  1768.  On  the  21st  of  July  in  the 
same  year  Heberden,  in  a  communication  to  the  Royal  College  of 


^  Known   variously   as    stenocardia,    sternalgia,   neuralgia   cordis,    asthma 
dolorificum,  syncope  dolorosa,  or  anginosa. 

^  Morgagni.  De  Sedibus.  II.  Epist.,  XXVI.,  31  et  seq. 
*  Peter,  Mai  du  Cceur,  Paris,  1883,  p.  662. 


2o8  Angina  Pectoris 

Physicians  in  London,  gave  it  the  name  angina  pectoris.  The  pic- 
ture he  drew  was  so  accurate  that  he  is  justly  recognized  as  having; 
been  the  first  to  contradistinguish  it  from  cardiac  asthma,*  a  dis- 
tinction which,  unfortunately,  is  not  always  kept  in  view  at  the 
present  day. 

In  1772,  we  are  told  by  Parry  (Angina  Pectoris,  London,  1799) 
that  Jenner  first  saw  calcification  of  the  coronary  arteries  in  a  speci- 
men dissected  by  John  Hunter,  and  in  the  year  1788  Parry  rec- 
ognized a  coincidence  between  sclerosis  of  the  coronary  vessels 
and  angina  pectoris. 

It  remained,  however,  for  W'alshe'  to  separate  it  into  two 
principal  varieties,  the  true  and  the  false,  a  valuable  distinction  from 
a  clinical  point  of  view.  The  false  variety,  sometimes  called  angina 
hysterica,  is  exceedingly  common  in  nervous  women,  without  any 
associated  anatomical  changes  in  the  heart  or  arteries. 

In  place  of  false  angina,  the  name  aiigina  pectoris-motoria  was, 
I  believe,  first  suggested  by  Landois,"  who  held  that  angina  par- 
took of  an  exaggerated  vasomotor  disturbance,'  and  found  it  in  chlo- 
rotic  or  anaemic  girls  undenr  emotional  or  cerebrospinal  disturbances,, 
which  caused  either  increased  arterial  tension  or  vasomotor  pare- 
sis. Under  this  same  name  sub-varieties  have  been  described,  nota- 
bly one  by  Nothnagel''  in  persons  whose  limbs  had  been  stiffened  by 
exposure  to  cold,  where  relief  was  obtained  by  external  heat.  Some- 
what analogous  cases  have  been  described  by  Bamberger. 

Others  have  preferred  to  divide  angina  pectoris  into  the  mild 
and  severe  forms,  and  there  is  some  reason  for  this  plan.  Occa- 
sionally the  false  or  pseudo  angina  will  produce  more  excru- 
ciating pain  than  the  true  variety.      I  have  known  such  instances. 

Inasmuch  as  coronary  disease  is  known  to  be  the  special  patho- 
logical concomitant  of  true  angina,  while  affections  of  the  great 
vessels  and  the  heart  are  of  less  frequent  occurrence,  some  regard 
the  former  as  primary  and  the  latter  as  secondary  causes. 

True  angina  is  certainly  a  very  rare  disease,  though  the  laity 
talk  glibly  about  it,  as  an  everyday  occurrence.  The  paroxys- 
mal attacks  that  eventually  carried  off  the  great  John  Hunter  and  the 


*  rieberden,    Commentaries   on    the   History   and   Cure   of  Disease,    1782, 
Chapter  LXX. 

''Walshe,  Dis.  of  the  Heart,   1873,  5th  4th   edition,  p.  209. 
°  Landois    ,Correspondenz-blatt   der  Deutsch.    Gesellsch.    fiir  Psychiatrie, 
January,    1866. 

'  Niemeyer  held  this  view. 

*  Nothnagel,  Special.  Path.,  XV.-2,  s.  592. 


Angina  Pectoris  209 

bony  hardness  of  his  coronary  arteries,  left  a  deep  impress  on  the 
minds  of  the  laity  and  medical  men  in  England,  and  its  effects  are 
still  seen.  But  how  many  of  the  prominent  men  supposed  to  have 
died  of  angina  really  died  of  ordinary  heart  diseases  or  apoplexy, 
we  shall  never  know.      Certainly  it  is  a  rare  disease  in  hospitals. 

In  a  series  of  823  cases,  fairly  complete  as  to  clinical  details 
and  autopsical  findings,  in  two  hospitals,  extending  over  a  term 
of  ten  years  in  one  and  fifteen  in  the  other,  I  have  no  recorded 
mention  of  a  single  instance  of  true  angina  pectoris.  And  yet 
coronary  diseases  were  common  enough. 

In  a  series  of  2,300  consecutive  cases  observed  by  Dr.  Abra- 
hams in  the  clinic  of  my  colleague,  Professor  Wainwright,  at  the 
Post-Graduate  Hospital  there  was  not  a  single  case  of  true  angina, 
pectoris,  though  false  angina  was  of  frequent  occurrence.  Pro- 
fessor Burt,  while  in  the  outdoor  department  of  Bellevue  Hospi- 
tal, in  the  division  for  heart  and  lungs,  with  an  average  of  600  new 
cases  a  month,  has  said  he  did  not  remember  to  have  seen  a  smgle- 
instance  of  it.  False  angina,  however,  was  common  in  women 
who  drank  strong,  rank  tea.® 

The  most  conspicuous  special  lesion  is  obstruction  of  the  coro- 
naries  by  atheroma,  or  deformative  arteritis,  with  or  without  em- 
bolism or  thrombosis.  In  John  Hunter's  case,  where  the  clinical 
signs  had  been  most  pronounced,  the  coronary  arteries  were  so  hard 
that  it  was  difficult  to  divide  them  with  a  knife,  and  their  transverse 
sections  did  not  collapse,  while  the  aortic^"  and  mitral  valves  showed 
"ossification,"  as  calcification  was  then  called. 

In  Gautier  and  Huchard's"  70  cases,  however,  there  was  coro- 
nary disease  in  only  38,  or  53  per  cent.  The  following  in  detail  were 
their  findings  in  angina  pectoris : 

Lesions  of  the  coronary  arteries  alone,  or  with  other 

cardiac  or  arterial   lesions    38 

Aortic   insufficiency    * 12 

Aneurism  of  the  arch   5 

Fatty  degeneration  of  the  heart 4 

Hypertrophy  and  dilatation    4 

Pericarditis    3 

Suppuration  into  mediastinum i 

Negative    3 

'  The  Post-Graduate,  Dec,  1904,  p.  1216. 
^"Adam,    Life  of  Hunter,  1817,  p.  203-4. 
"Tacchi,   Gas.   Med.   di  Rom.,   1890,   XVI.,   p.   97 


2IO  Angina  Pectoris 

In  a  later  coniniunication,  liowevcr,  liuchard'-  has  given  a  dif- 
ferent result.  In  the  145  eases  he  collected  he  found  the  eoronaries 
affected  in  128,  or  88  per  cent.,  and  as  follows: 

In  64   both  eoronaries. 

In  37    the  left  coronar\-. 

In   15    the  right  coronary. 

In  12   not  specified. 

In  all  (.if  the  128  there  was  obstruction  or  stenosis,  121  times 
by  atheromatous  stricture  or  thrombosis,  tive  times  by  embolism, 
twice  by  compression.  The  other  cardiac  lesions  were  regarded  as 
of  minor  importance. 

And  yet,  it  should  be  remembered  that  he  appears  to  have  been 
able  to  collect  only  128  cases  of  coronary  disease  associated  with 
angina,  while  thousands  of  cases  of  coronary  disease  unconnected 
with  angina  could  be  equally  well  collected,  if  any  one  were  to  make 
a  search  for  them.  In  my  own  experience  I  should  be  quite  willing 
to  say  that  1  have  seen  hundreds  of  cases  of  coronary  disease  with- 
out a  single  manifestation  of  angina  pectoris. 

It  may  also  be  said,  in  explanation  of  Huchard's  statistics,  that 
during  the  period  of  life  when  angina  is  most  prevalent,  viz.,  be- 
tween 50  and  60,  degeneration  of  the  coronary  arteries  is  the  rule 
rather  than  the  exception.  To  put  it  even  stronger,  most  per- 
sons after  middle  life  have  arterial  disease,  and  many  at  a  much 
earlier  period   of   life. 

In  order  to  realize  the  diversity  of  opinion  that  has  prevailed 
as  to  the  cause  of  the  j^ain,  we  have  but  to  consider  the  views  held 
by  prominent  men. 

Heberden  thought  it  was  due  to  the  contraction  of  a  hollow 
organ  (the  heart),  and  he  compared  it  with  the  spasm  of  hollow 
viscera,  such  as  the  intestines  and  the  uterus,  contractions  of  which, 
we  know,  produce  violent  pain.  This  theory  would  appear  to  ne- 
cessitate some  alteration  in  the  pulse,  which,  as  a  matter  of  fact, 
is  not  apt  to  be  altered  in  rhythm,  though  there  may  be  often  and 
perhaps  usually  is,  I  think,  some  hypertension. 

Some  have  regarded  it  as  a  paralysis  of  the  heart.  Undoubt- 
edly, if  angina  should  result  in  death,  there  would  be  paralysis  of 
the  left  ventricle.  Others  have  held  that  it  is  a  manifestation 
of  gout;  but  often  there  are  no  lithaemic  manifestations.  The  neu- 
rotic theory  was  early  advanced.  Laennec^-  and  Lartigue^^  thought 
it  originated  in  the  pneumogastric,  and  Lancereaux.  Peter,  and 
Bazy"  found,  in  several  autopsies,  apparent  infiltrations  of  the  car- 

"  Laennec,  Dts.   of  the   Chest,   1834,   p.   65. 
"Lartigue   Gaz.   Med.   de  Paris,   1847,   0.   775- 
"Peter,  Mai.  du  Caur.  p.   703. 


Angina  Pectoris  211 

diac  plexus ;  but  on  the  other  hand,  infiltration  of  this  plexus  by 
exudations  or  new  growths  does  not  always  produce  pain,  and  if 
this  latter  view  is  correct,  it  should  be  permanent.  But  the  pains 
of  angina  are  only  temporary. 

Friedreich'^  and  Romberg'"  thought  it  a  functional  afifair,— a 
neurosis.  Trousseau'^  compared  it  to  the  nerve  explosion  of  epi- 
lepsy. Bouillaud''*  ascribed  the  pain  to  phrenic  and  intercostal  irri- 
tation. Piorry'^'-'  called  it  a  brachio-thoracic  neuralgia.  Allan 
Burns^°  located  it  in  the  cardiac  vessels,  which  by  their  stiffness  re- 
sist the  blood-pressure,  whenever  the  other  systemic  vessels  are  dis- 
tended. 

Deprivation  of  blood  as  in  embolism  will,  it  is  known,  cause 
severe  pain  sometimes,  but  not  always.  Lauder-Brunton-'  has  held 
that  the  pain  is  due  to  rise  in  tension  of  the  peripheral,  i.  e.,  coro- 
nary arteries,  and  experiments  made  by  him  in  1867  suggested  the 
use  of  the  nitrite  of  amyl,  a  vasodilator,  which  has  been  successful. 
This  is  strong  proof,  certainly,  that  the  pain  is  due  to  hypertension 
of  the  vessels.  There  are  some  difficulties,  however,  in  this  the- 
ory, viz.,  that  in  such  instances  as  Hunter's  the  coronaries  were  too 
stiff  to  contract.  And  yet  hypertension  may  have  taken  place  in 
the  arterioles  and  capillaries.  Indeed,  we  cannot  imagine  that 
nutrition  of  the  organ  could  have  been  maintained,  without  a  suffi- 
ciently healthy  tone  in  a  goodly  portion  of  the  vessels,  to  allow  of 
their  functioning. 

Somewhat  akin  to  this  is  the  view  of  Nothnagel  that  the  pain 
is  due  to  a  spasm  of  the  vasomotor  nerves  of  the  heart,  causing 
great  increase  in  blood-pressure.  Albutt--  has  claimed  that  the 
pain  is  not  cardiac. 

Another  view  is  that  there  is  a  circumscribed  ischsemia  from 
deficient  blood  supply  to  the  heart  walls,  and  the  effect  is  like  that 
produced  by  pressure  of  a  distended  stomach  on  the  heart.  In 
this  connection  it  is  well  to  know  that  the  coronaries  often  terminate 
in  comparatively  large  trunks,  from  which  capillaries  are  given  off, 


"  Friedreich,    Traite   des   Mai    du    Cceur,   Paris,    1873,   p.    531. 

"  Romberg,  Dis.  of  the  Nervous  System,  London,   1853,  Vol.  I.,  p.   125. 

"Trousseau,  Clin.  Med..  London,   1868,  Vol.  L,  p.  592. 

^  Bouillaud,  Mai.  du  Cceur,  Paris,  1841,  Vol.  IL  p.  613. 

"  Piorry,   Traite  de  Med.  Prat.,  Paris,   1842,  Vol.  VIIL,  o.   143. 

*°  Burns,  Dis.  of  the  Heart,  Edinburgh,   1809,  p.   136. 

"  Lauder  Brunton,  Pharm.   Ther.   aiid  Mat.  Med.,   1885,   p.  666. 

^  Allbutt,  Phil.  Med.  Journal,  June   16,    IQOO. 


212  Angina  Pectoris 

and  that  these  unite  to  form  reservoirs  between  the  niusele  fibres 
while  the  capillaries  freely  anastomose,  so  that  interference  with 
the  circulation  in  a  cardiac  artery  means  interference  with  a  large 
amount  of  capillary  tissue.  This  anatomical  peculiarity  indicates 
that  there  is  a  peculiar  vascular  network  in  ilie  walls  of  the  heart, 
and  that  contractions  of  these  vessels  and  reservoirs  may  cause  pain- 
ful sensations,  unlike  any  others  in  the  body. 

Out  of  these  facts  and  theories,  diverse  as  thev  are,  a  few  im- 
portant data  can  be  elicited,  which  are :  The  most  predominating 
lesions  that  have  thus  far  been  observed  have  been  coronary  dis- 
eases :  and  with  a  great  deal  less  frequency,  atheroma  of  the  as- 
cending portion  of  the  arch,  aortic  endocarditis,  or  some  form  of 
heart  disease,  or  perhaps  pericarditis.  With  the  angina  there  is 
sometimes  high  blood-pressure  in  the  left  ventricle,  and  apparently 
any  cause  that  will  produce  high  arterial  tension  will  in  certain 
persons  precipitate  an  attack.  The  pneumogastric  is  probably  im- 
plicated, as  indicated  by  the  spasmodic  action  of  the  stomach,  which 
expels  gas  in  great  quantities,  at  the  close  of  an  attack.  On  the 
other  hand,  the  passage  of  a  large  amount  of  a  pale  colored  urine 
implies  that  the  sympathetic  is  also  involved,  and  this  view  is 
strengthened  by  the  fact  that  various  forms  of  excitation  in  remote 
parts  will  also  precipitate  an  angina.  Inasmuch,  however,  as  these 
attacks  partake  at  one  time  of  neuralgia  in  one  nerve  and  then  of 
another,  the  spinal  cord  must  be  the  medium  of  transmission  of  the 
nerve  impulses.  And  as  fright  will  bring  on  an  attack,  the  cere- 
brum at  times  is  involved.  Furthermore,  it  may  have  a  toxic 
origin.  For  example,  it  may  be  due  to  an  excess  in  tobacco,  tea 
or  coffee.  Huchard  claims  that  tobacco  causes  a  functional  spasm 
of  the  coronaries,  and  his  contention  may  be  correct. 

Angina  has  a  hereditary  character ;  but  then,  the  varioufe  under- 
lying conditions,  such  as  nervous  excitability,  coronary  disease,  and 
arteriosclerosis  are  also,  in  a  large  measure,  hereditary. 

The  exciting  causes  are  known  to  be  unusual  muscular  activity 
and  sudden  emotions  or  reflexes,  especially  from  the  abdominal 
organs. 

The  pathogenesis  of  angina  must  therefore,  at  times  certainly,  be 
referred  to  the  central,  peripheral,  motor,  or  sensory  filaments  of 
the  entire  nervous  system. 

True  angina  has  been  chiefly  observed  in  males.  Pye-Smith 
found  that  the  proportion  was  7  to  i ;  others  have  made  the  ratio 
even  greater.      In  Huchard's  237  cases  of  true  angina  his  propor- 


Angina  Pectoris  213 

tion  was  195  men  to  42  women  (about  5 — i)  ;  in  his  141  pseudo 
cases  98  were  women  and  43  men  (al)fjut  3 — i).  True  angina 
rarely  occurs  before  40;  usually  between  50  and  60.  \n  Forbes'^^ 
cases  y2  out  of  84  were  over  50. 

When  an  attack  of  true  angina  seizes  a  patient,  the  pain  is 
usually  referred  to  the  sternum,  about  its  middle.  It  is  apt  also 
to  radiate  down  the  left  arm,  less  often  down  the  right  arm  or 
even  leg,  sometimes  to  various  parts  of  the  abdomen  or  pelvis.  An 
angina  sine  dolore  has  also  been  described.  It  reminds  one  of  the 
play  of  Hamlet,  with  the  part  of  Hamlet  omitted.  However,  it  has 
been  spoken  of  as  a  dull  ache,  replacing  the  regular  attack  with  all 
the  concomitant  symptoms  except  the  excruciating  pain. 

In  a  well  marked  instance  of  true  or  severe  angina,  the  face 
will  ordinarily  be  pallid,  and  the  forehead  covered  with  sweat, 
while  the  respiration  is  not  afifected ;  this  condition  contrast- 
ing sharply,  therefore,  with  the  cardiac  asthma  of  valvular  or 
myocardial  disease.  The  heart's  action  may  be  increased  or  di-. 
minished,  or  may  be  unaffected.  Unless  death  is  imminent,  the 
pulse  is  usually  regular  and  of  ordinary  frequency.  As  the  attack 
passes  off,  a  sensation  of  weakness  is  felt.  Sometimes  there  is 
formication  or  numbness,  afterwards  usually  belching  of  wind  and 
the  discharge  of  urine  of  low  specific  gravity  and  pale  color ;  all 
of  which  betray  the  essentially  neurotic  character  of  the  disease. 

The  pain  is  a  distinctive  feature  of  true  angina,  but  it  is  in 
no  sense  a  pressure  pain.  It  is  the  pain  of  an  intense  neuralgia, 
so  excruciating  that  the  patient  feels  that  he  must  keep  absolutely 
still  until  it  has  passed.  In  my  experience  the  "sense  of  impending 
death"  has  not  been  a  prominent  feature,  but  on  several  occasions 
the  patients  have  expressed  themselves  as  feeling  that  the  chest  was 
being  compressed,  as  if  in  a  vise.  In  one  instance  the  patient  said 
she  felt  as  if  a  "house  were  resting  on  her  chest."  But  there  are 
degrees  in  the  amount  of  pain  felt.  The  attack  is  usually  brief, 
more  especially  after  the  first  attack,  for  then  the  patient's  experi- 
ence has  taught  him  or  her  how  to  manage  the  seizure.  Usually 
of  only  a  few  minutes'  duration,  it  may  last  several  hours,  and  in 
one  of  my  cases  an  intense  angina  continued  for  several  da}"s. 

The  immediate  cause  of  an  attack  may  be  due  to  several  causes, 
as  I  have  already  mentioned.  In  one  of  my  cases  it  was  produced 
by  sexual  intercourse,  in  another  by  the  smell  of  fresh  paint,  and 
in  a  third  by  prolonged  conversation.     A  common  cause  is  undue 


"^Walshe,  p.  203. 


214  Angina  Pectoris 

hurry,  or  walking-  in  the  face  of  a  sharj)  wind.  In  one  of  my 
patients  it  seemed  as  if  the  gastro-intestinal  distention  was  the 
cause  of  the  attack  ;  certainly,  it  was  the  forerunner  of  it. 

Death  has  been  ascribed  to  poisoning  of  the  heart  muscle  by 
the  arrested  metabolism,  but  this  process  is  too  slow  to  explain  it. 
The  causes  arc  various.  It  may  be  due  to  paralysis  from  deficient 
innervation,  or  the  pressure  of  abdominal  organs,  such  as  the 
stomach,  which  as  a  rule  is  overdilated. 

Reflex  Angina  Pectoris,  the  angina  vasomotoria  of  Landois, 
is  associated  with  visceral  or  peripheral  disturbances,  without 
known  organic  lesions.  Peripheral  neuralgias  are  supposed  to  be 
exciting  causes.  It  will  be  noted,  however,  that  such  peripheral 
neuralgias  are  alleged  to  have  excited  true  angina.  In  the  hys- 
terical variety  there  should  be  the  characteristics  of  hysteria  pres- 
ent. Pains  in  other  localities,  with  hyper?esthetic  areas,  should 
be  associated.  While  the  distinction  between  true  and  false  angina 
is  theoretically  easy,  it  may  be  very  difficult. 

All  the  circumstances  of  the  case  must  be  considered  in  making 
a  differential  diagnosis.  If  in  the  male  sex,  after  50,  and  in 
association  with  general  arteriosclerosis  and  some  form  of  heart 
disease,  of  the  aortic  valve  particularly,  the  diagnosis  of  true  an- 
gina may  be  made  with  a  considerable  degree  of  confidence. 

On  the  other  hand,  in  young  people,  women  especially,  of 
neurotic  history  and  lowered  vitality,  in  the  absence  of  arterio- 
sclerosis or  any  form  of  heart  disease,  the  diagnosis  of  pseudo- 
angina  may  be  made  with  an  equal  degree  of  confidence. 

In  angina  from  poisoning  by  tobacco,  tea  or  coffee  there  is 
the  history  of  indulgence  in  these  luxuries,  with  their  associated 
cardiac  and  neurotic  symptoms,  that  cease  w^hen  the  cause  is  re- 
moved. As  regards  the  differential  diagnosis  from  cardiac  asth- 
ma, we  see  actual  dyspnoea  in  the  latter.  In  pseudo-angina  there 
is  never  any  actual  dyspnoea,  for  the  patient  can  draw  a  long  breath 
if  he  makes  the  attempt.  In  cardiac  asthma  there  is  engorgement 
of  internal  organs,  and  externally  we  see  the  physical  signs  of 
venous  congestion.  There  may,  however,  be  instances  in  which  it 
is  very  difficult  to  distinguish  between  the  true  and  false  forms,  as 
I  have  already  said. 

Nitrite  of  amyl  is  often  a  specific  in  the  treatment  of  true 
angina.  A  few  drops,  three  to  five,  according  to  the  severity 
of  the  attack,  placed  on  a  handkerchief  relieve  the  patient.  Nitro- 
glycerine taken  by  the  mouth  in  doses  of  i/ioo  or  1/50  of  a  grain  will 


Angina  Pectoris  215 

sometimes  give  relief  in  less  than  a  minute.  I  use  for  this  purpose 
a  capsule  containing  nitroglycerine  gr.  i/ioo,  menthol  gr.  1/50, 
amyl  nitrite  gr.  1/4,  with  oleo  resin  of  capsicum,  gr  i/ioo.  Attacks 
occurring  in  my  (jffice  or  in  my  presence  arc  thus  easily  relieved. 
But  the  nitrite  of  amyl  alone  is  not  always  sufficient ;  in  chronic 
cases  it  sometimes  fails  to  give  relief. 

In  cases  where  these  remedies  are  not  at  hand,  morphine  should 
be  used  hypodermically,  and  then  followed  up  by  inhalation  of 
chloroform  or  ether,  without  waiting  for  the  morphine  to  act.^*  The 
patient  may  pour  a  few  teaspoonfuls  of  ether  into  a  saucer  and 
inhale  the  fumes.  Balfour's-^  plan  is  to  put  a  sponge  soaked  in 
chloroform  into  a  wide-mouthed  bottle,  and  then  allow  the  patient 
to  inhale  the  fumes  until  he  gets  relief.  Heat  applied  to  the  chest 
by  a  hot  water  bottle  or  bag,  replaced  by  mustard  leaves  or  poul- 
tices, will  often  give  relief.  Cold  applications,  however,  are  some- 
times quite  as  useful. 

If  there  is  any  sign  of  heart  failure,  brandy,  whiskey  or  carbon- 
ate of  ammonium  are  indicated,  the  latter  being  almost  universally 
applicable.  Digitalis  is  too  slow  to  be  useful.  In  a  case  I  saw  re- 
cently I  found  the  aromatic  spirit  of  ammonia  of  the  greatest  as- 
sistance. It  also  promoted  the  expulsion  of  gas  by  the  rectum. 
After  the  paroxysm  has  passed,  aconite  will  be  found  useful  in 
two  minim  doses  t.i.d. ;  also,  later,  arsenious  acid  in  i/ioo  grain 
doses.  If  there  is  arteriosclerosis,  arsenic  should  be  kept  up  for 
a  while  and  then  replaced  by  iodide  of  potassium,  sodium,  or  stron- 
tium, in  from  one  to  five  or  ten  grain  doses. 

In  the  pseudo  cases  Hoffman's  anodyne  is  indicated,  or  the 
monobromate  of  camphor  in  grain  doses,  asafcetida  in  three  to  ten 
grain  doses,  and  finally  musk  in  five  to  eight  grain  doses.-*'  The 
cretaegus  oxycantha  or  hawthorn  has  been  used  with  benefit.  The 
dose  is  five  to  twenty  drops  of  the  tinct.  t.i.d.  I  have  used  it,  but 
not  sufficiently  to  speak  of  it  with  positiveness.  Some  prefer  the 
nitrites.  They  are  used  extensively  in  England  and  France.  The 
nitrite  of  sodium  is  a  remedy  I  sometimes  use  in  doses  of  from  one 
to  three  grains  three  times  a  day.  It  may  be  used  as  a  preventive, 
and,  as  such,  mv  friend.  Dr.  Abrahams,  uses  it. 


^*  The  tendency  to  formation  of  an  opium  habit  in  this  disease  must 
be  kept   in   mind. 

"°  Balfour's  Dis.  of  the  Heart,  London,   1898,  p.  331. 

"^  I  have  recently  been  using  the  iodo-nucloids  made  in  tablet  form  by 
a  Chicago  house.  Each  tablet  contains  a  half  grain  of  iodine,  and  I  give 
as  much  as  2  to  2%  grains  three  times  a  day.  The  tablets  are  well  borne  by 
the  stomach. 


2i6  Angina  Pectoris 

In  one  case  of  what  1  then  hchevctl  was  true  angina,  in  a  young 
married  woman,  where  the  ixiin  was  agnnizing-,  I  oave  complete 
relief  by  tlie  continuous  current ;  certainly  the  jiain  did  not  recur  dur- 
ing the  weeks  she  was  under  my  care. 

As  to  the  prognosis  in  true  angina  of  the  primary  variet\-,  mean- 
ing by  this  where  there  is  no  associated  disease  of  aorta  or  aortic 
or  other  forms  of  organic  heart  disease.  I  do  not  know  that  we  are 
prepared  to  form  an  o])ini(iii.  Coronar}-  disease  itself  is  quite  com- 
patible with  a  fairl}-  lung  life,  judging  from  the  frecpiency  with 
which  it  is  found  at  post-mortems ;  but  in  the  secondary  form 
the  forecast  is  certainly  worse.  And  yet  it  is  uncertain.  There  is 
apt  to  be  an  interval  of  a  year  or  so.  at  any  rate,  between  the  at- 
tacks ;  and  the  disease  may  continue  for  years.  It  has  been  known 
to  exist  in  some  instances  from  30  to  40  years.  And  yet  a  single 
attack  may  be  fatal  at  any  time,  we  may  well  believe  ;  for  it  only 
requires  sudden  paralysis  of  the  left  ventricle,  or  the  larger  part 
of  it.  And  yet  the  patient  may,  in  exceptional  instances,  entirely 
recover. 

If  he  can  live  where  he  is  not  exposed  to  cold  or  to  excitement 
and  avoids  hurry  and  digestive  and  other  excesses,  his  chances  are 
vastly  improved,  for  it  is  just  these  conditions  that  often  bring  on 
an  attack. 

Case  LXXl'III.  True  Angina  Pectoris;  Aortic  Regurgitation; 
Lithccmia. — B..  54,  liquor  dealer,  came  to  my  clinic  at  the  Post- 
Graduate  School,  passing  a  high-colored  urine  loaded  with  uric 
acid,  but  without  a  previous  history  of  rheumatism.  No  syphilis. 
Five  vears  previously  he  had  first  experienced  palpitation  and 
dvspnoea.  with  "soreness"  in  the  region  of  the  heart.  Three  years 
later  he  developed  what  was  classed  as  angina  pectoris,  pains  of  a 
"darting"  character  located  in  the  heart  and  running  down  the  left 
arm,  rmd  accom])anicd  by  a  "sense  of  im]XMiding  death." 

Un  physical  examination,  the  impulse  was  found  to  be  much 
diffused  and  weak.  Aortic  reguurgitant  murmur.  Water-hammer 
pulse  in  all  the  arteries.  After  protracted  treatment,  lasting  over 
six  months,  bv  alkalies,  hepatics  and  iodides,  it  is  noted  in  the  record 
kept  by  my  clinical  assistants,  that  "he  was  much  improved." 

Case  LXXIX.  Angina  Pectoris;  Arteriosclerosis;  Glycosuria; 
Albuminuria;  Apoplexy. — Mr.  H.,  a  retired  merchant,  74  years 
old,  of  full  habit  and  rather  obese,  was  sent  to  me  in  September, 
1899,  by  Dr.  H.  V.  Barclay.  He  had  been  complaining  of  dys- 
phagia and  obscure  gastric  attacks  coming  on  at  night.     On  phys- 


Angina  Pectoris  217 

ical  examinati(jn  his  pulse  was  found  to  Ijc  80  and  feeble,  with 
hard  radials,  rollinj^  under  the  fingers.  Respiration  24.  imijulse 
at  apex  hard  to  detect.  Apex  one-half  inch  outside  the  nipple  and 
one-half  inch  below  the  intermammillary  line.  Heart  sounds  in- 
distinct. One  and  one-fourth  ])er  cent,  sug-ar  in  urine.  Traces 
of  albumin;  specific  gravity  1015.  He  was  put  on  carbonated 
baths  and  resistance  exercises.  Owing  to  his  feeble  condition  the 
baths  and  exercises  were  stopped  on  the  13th  day  of  treatment. 
On  this  day  he  had  a  gastric  crisis  at  night,  and  the  next  morning 
his  head  was  confused.  On  October  23  a  musical  murmur  was 
heard  with  systole  at  the  apex.  He  was  now  ]nit  cm  potassium 
iodide.  Two  or  three  attacks  of  angina  had  been  brought  on  by 
the  smell  of  cooking,  and  others  by  gastric  or  intestinal  distention. 
On  October  27  an  attack  was  induced  in  my  office  by  a  smell  of 
fresh  paint.  Relief  was  obtained  by  capsules  of  nitrite  of  amyl 
with  nitroglycerine,  etc.,  the  formula  of  which  I  have  given.  Pa- 
tient nervous  and  hysterical.  For  three  weeks  he  was  free  from 
attacks,  using  the  capsules  only  to  ward  off  attacks,  but  his  diet 
was  restricted.  Under  the  iodide  of  sodium  increased  to  nine 
minims  of  the  saturated  solution,  three  times  a  day,  the  patient 
■continued  to  improve,  although  he  had  occasional  attacks  of  diz- 
ziness, and  was  troubled  by  a  sound  like  that  of  running  water  in 
his  right  ear,  indicating  the  gravity  of  the  disease  in  his  cerebral 
arteries.  Like  many  old  men  with  arterio-sclerosis,  however,  he 
became  restless  under  treatment,  and  in  December  passed  from 
Tinder  my  care.  In  the  following  February  he  died  of  an  apoplectic 
attack. 

In  cases  of  advanced  arteriosclerosis  like  this  one,  the  prognosis 
must  be  bad.  No  remedy  has  yet  been  found  that  will  cure  calci- 
fication of  a  vessel.  The  following  case  may  or  may  not  have  been 
■one  of  true  angina: 

Case  LXXX.  Angina  Pectoris;  Direct  Aortic  Munnur;  Cya- 
nosis; Flatulent  Dyspepsia;  Superficial  Oedema. — A  young  married 
woman,  of  fine  physique,  weighing  140  pounds,  was  referred  to  me 
by  her  physician.  She  had  been  ill  for  five  or  six  years,  and  for  the 
previous  eight  months  had  been  under  active  treatment  for  her 
heart  affection.  Notwithstanding  this,  she  grew  gradually  worse. 
Previous  to  her  illness  she  had  been  given  to  athletic  sports,  such 
as  riding,  swimming,  etc.  The  attacks  of  angina  were  regarded  by 
Tier  physician  as  of  the  true  variety.  The  prjecordial  pain  was  de- 
sciibed  as  of  "a  house  resting  on  the  chest."     Flatulent  dyspepsia, 


2i8  Angina  Pectoris 

dyspncEa  and  transient  cyanosis  were  other  symptoms  given.  At- 
tacks were  brought  on  by  nervous  strain  of  any  kind,  particularly 
by  prolonged  conversation.  They  were  temporarily  relieved  by 
nitroglycerine. 

On  physical  examination  the  pulse  was  found  to  be  80,  soft 
and  weak,  but  without  intermission.  No  impulse  at  the  apex,  but 
burning  pain.  No  thrill ;  praecordium  and  sternum  sensitive  to  the 
touch  and  swollen;  cording  of  lymj^hatics  imder  left  breast;  apex 
under  sixth  rib  %  inch  inside  of  mammilla  and  2^  inches  below 
intermammillary  line ;  at  apex  slight  systolic  murmur.  At  base 
systolic  munnur  carried  well  up  into  the  great  vessels. 

Potassium  citrate,  nitroglycerine,  strophanthus  and  strychnine 
had  been  given.  I  ordered  all  medicine  stopped,  and  gave  cam- 
phor monobromate  in  two  grain  doses,*  carbonated  baths,  and  re- 
sistance exercises,  with  massage.  After  four  days  of  this  treat- 
ment the  swelling  of  the  breasts  had  disappeared,  and  in  fifteen- 
days  she  was  sufficiently  improved  to  return  home.  In  the  lollpw- 
ing  September  she  was  enjoying  life,  camping  in  the  Maine  woods,, 
and  feeling,  as  she  expressed  it,  "restored  to  health." 

This  ]~)atient  reports  to  me  from  time  to  time  and  has  had  nO' 
recurrence  of  her  angina  since  the  above  treatment,  which  was. 
in   1900. 

The  following  is  an  example  of  the  false  form : 

Case  LXXXI.  Cardiac  Dilatafioi :  Mitral  Regurgitation;  Irri- 
table Heart. — Mrs.  R.,  a  young  married  woman,  was  referred  to  me 
in  January  of  1899.  She  was  slight  in  build  and  a  neurotic  subject, 
addicted  to  h}-sterical  seizures  ;  had  morbid  fears,  pseudo  angina,, 
insomnia  and  gastric  disturbances,  with  constipation.  Her  med- 
ical treatment,  prior  to  my  taking  her  under  my  care,  had' 
consisted  of  stomachics,  laxatives  and  sedatives.  On  examina- 
tion February  i  her  apex  was  found  in  the  fifth  space,  in- 
the  line  of  the  nipple.  At  the  apex  harsh  and  distinct  systolic- 
murmur,  carried  round  to  the  left.  At  the  base  a  soft  systolic  mur- 
mur, confined  to  the  aortic  area.  Heart  sounds  feeble.  Pulse  in- 
termittent. Urine  normal.  After  a  preliminary  rest  and  atten- 
ion  to  her  general  condition  she  was  ordered  a  limited  nuniber  of" 
1-novements,  each  lasting  fifteen  minutes.  These  were  gradually 
increased  in  number  for  eight  consecutive  weeks,  given  daily  with 
constantly  increasing  force,  with  the  result  that  the  heart 
sounds  became  more  distinct,  the  basic  murmur  disappeared, 
the  menstrual   flow   increased,   and   the   attacks  became   gradually 


Angina  Pectoris  219 

milder,  while  there  was  marked  general  improvement.  During  the 
six  weeks  following  the  end  of  the  treatment  she  had  but  one  at- 
tack. The  apex  had  moved  towards  the  median  line  19/^  inches. 
The  contraction  of  the  heart  in  this  case  of  dilatation  goes  far,  in  my 
mind,  towards  proving  that  the  pain  of  angina  is  due  to  dilatation. 
I  believe,  however,  that  it  is  often  more  than  dilatation.  There 
may  also  be  spasm,  as  Heberden  held.  Unequal  tension  expresses 
this  double  condition,  according  to  my  view.  But  how  explain  the 
unequal  tension  on  the  theory  that  coronary  disease  is  an  important 
factor?  In  this  way,  if  you  choose:  Coronary  disease  produces 
fatty  degeneration  of  the  heart,  because  the  supply  of  blood  to  the 
organ  is  insufficient,  the  result  being  weak  spots  corresponding  to 
the  areas  that  are  imperfectly  nourished.  The  heart  muscle,  there- 
fore, cannot  contract  evenly,  and  the  very  unequal  tension  causes 
the  greater  pain.  Charcot  held  the  view  that  it  was  due  to  local 
spasm,  similar  to  the  local  spasms  of  the  intestine  in  influenza,  the 
fibrillary  contractions  of  facial  muscles  in  cerebral  disease  or  the 
spasm  of  the  muscles  of  the  extremity  in  the  "intermittent  claudi- 
cation" of  Bouley,  the  veterinarian,  who  first  saw  it  in  horses. 

In  the  last  of  my  cases,  that  of  false  angina,  I  would  explain  the 
pain  as  caused  by  spasm  of  the  cardiac  muscular  tissue  of  the  heart, 
which  in  this  case  was  essentially  normal.  The  contractions  pressed 
on  the  nerves  and  ganglia,  causing  the  pain,  and  each  spasm  left  the 
nerve  elements  more  irritable  and  more  predisposed  to  another  at- 
tack. 

This  theory  will,  therefore,  explain  the  cause  of  the  pain  in 
both  the  true  and  false  forms.  In  fact,  the  closer  we  look  at  the 
two,  the  less  essential  are  the  differences  between  them. 


Chapter  XIX. 

THE  GENERAL  MANAGEMENT  OF  HEART  DISEASES. 

'  As  distinguished  from  tlie  special  treatment  aj^plicable  to  the 
several  varieties  of  heart  disease,  their  t;encral  management  is  to  be 
considered. 

First  of  all.  we  should  hold  in  mind  the  particular  variety  and 
stage  of  the  disease  we  are  treating,  and  at  the  same  time  the  nat- 
ural limitations  of  all  remedies,  so  far  as  their  therapeutic  actions 
are  concerned.  This  statement  is  obviously  a  truism,  and  it  will  be 
so  admitted,  in  the  abstract ;  but  in  the  concrete,  that  is,  in  actual 
practice,  its  force  is  not  fully  recognized.  Take,  for  example, 
digitalis.  It  is  too  apt  to  be  prescribed  in  all  forms  of  heart  dis- 
ease. This  is  certainly  wrong.  While  the  drug  is  admirably  suited 
for  broken  compensation,  with  renal  inadequacy,  it  is  as  positively 
contra-indicated  in  cardiac  neuroses,  like  the  "tobacco  heart,"  and  is 
absolutely  dangerous,  if  there  is  a  tendency  to  apoplexy.  Again, 
while  the  salicylates  have  a  specific  action  in  acute  rheumatic  endo- 
carditis, they  are  only  prophylactics  in  the  chronic  forms.  Further- 
more, as  I  shall  endeavor  to  show,  each  cardiac  drug  has  a  specific 
and  limited  sphere  of  utility.  These  facts  do  not  always  have  their 
proper  weight,  when  cardiac  drugs  are  ordered  by  physicians. 

Though  this  chapter  is  devoted  to  treatment  rather  than  prophy- 
laxis. It  may  be  said  that,  inasmuch  as  endocarditis  is  usually  a 
secondary  phenomenon  in  constitutional  affections,  such  as  lithsemia 
or  the  exanthems,  or  in  some  septic  poisons,  as  in  the  malignant 
forms  of  cardiac  disease,  it  follows  naturally  that  successful  treat- 
ment of  the  primary  disease  should  favorably  influence  its  secondary 
manifestations.  When,  however,  endocarditis  has  supervened,  the 
constitutional  disease  should  be  treated,  as  well  as  the  special  cardiac 
manifestations.  Of  course,  in  the  acute  stage  rest  in  a  supine  posi- 
tion is  indicated ;  also,  local  applications  of  a  cooling  nature ;  per- 
haps opiates  ;  possibly  counterirritants  to  the  praecordium.  But  thus 
far  I  have  not  seen  the  necessity  for  adopting  Caton's^  plan  of  giv- 
ing mercurials  and  iodides  during  this  stage,  though  it  goes  without 
saying  that  they  are  positively  necessary  in  some  of  the  chronic 
forms. 

In  malignant  endocarditis  I  have  been  sceptical,  until  recently, 

^British  Medical  Journal,  Feb.  9,  1901. 


The  General  Management  of  Heart  Diseases  221 

of  a  cure  under  any  circumstances.  So  far  as  my  experience  has 
gone,  these  cases  have  proved  to  be  py^emic  in  character ;  so  that 
the  chances  of  recovery  can  hardly  be  much  better  than  in  pyaemia. 
But  I  have  seen  recovery  in  pyaemia,  and  I  do  not  close  my  eyes  to 
the  records  of  other  successful  cases.  The  sulpho-carbolate  of 
sodium  in  2-5  grain  doses,  or  other  intestinal  antiseptics  at  fre- 
quent intervals,  injections  of  streptococcus  serum;  colloidal  silver 
(Argentum  Crede)  by  inunction  in  10  per  cent,  strength,  for  adults, 
or  in  1/6  grain  doses  2-3  times  a  day,  in  pill  form,  ofifer  at  least 
some  hope  of  relief,  where  without  antiseptic  treatment,  in  some 
form  or  other,  the  forecast  is  very  gloomy. 

In  the  treatment  of  valvular  diseases  we  recognize  three  stages. 
First,  a  gradual  evolution  of  the  affection  with  the  production  of 
dilatation  and  hypertrophy.  Second,  a  stationary  period  where 
dilatation  and  hypertrophy  counterbalance  the  valvular  changes. 
Third,  a  period  in  which  the  equilibrium  of  the  cardiac  mechanism 
is  lost.  The  first  period  includes  and  outlasts  the  acute  exacerba- 
tion, but  continuing  until  compensation  is  established,  it  may  have 
a  duration  of  months,  or  even  years.  So  far  as  the  treatment  of  this 
stage  is  concerned,  after  the  febrile  period  is  passed,  an  effort  should 
be  made  to  arrest  the  constitutional  disorder.  Attention  should  be 
given  to  each  morbid  symptom ;  the  diet  should  be  so  regulated  as 
to  conform  to  individual  idiosyncracies  ;  errors  of  digestion  should 
be  corrected ;  overexertion  of  every  kind,  and  exposure  to  cold  or 
sharp  winds,  should  be  avoided.  The  patient  should  also  be  warned 
against  great  altitudes ;  also  the  superheating  of  the  body  in  a 
damp,  hot  atmosphere,  as  in  the  Turkish  or  Russian  bath. 

If  he  is  an  intelligent  adult,  it  is  best,  at  the  outset,  to  explain  to 
him  the  nature  of  his  malady,  so  as  to  secure  his  cooperation.  I 
know  of  no  disease  where  it  is  so  important  for  the  patient  to  thor- 
oughly understand  his  physical  limitations.  Concealment  of  them 
is  a  fundamental  error,  that  many  of  us  have  committed  in  times 
gone  by.  If  the  patient  is  property  informed,  however,  the  chances 
are  that  with  comparatively  little  medication  he  will  pass  success- 
fully through  this  stage.  In  fact,  a  couple  of  grains  of  the  mono- 
bromate  of  camphor  for  his  palpitation,  or  a  minim  or  two  of  the 
tincture  of  aconite  every  few  hours,  will  usually  so  modify  this 
symptom,  as  to  make  it  bearable,  if  it  is  not  arrested ;  while  glonoin 
in  i/ioo  grain  doses,  or  a  nitrite,  in  one  grain  doses,  every  hour, 
even  in  threatened  heart  failure,  will  often  be  sufficient. 

In  the  second  or  stationary  period,  the  patient  has  reached  a 


222  The  General  Management  of  Heart  Diseases 

plane  of  tolerable  safet}-.  Alarming  cardiac  symptoms  due  to  lack 
of  compensation  have  disappeared.  Theoretically,  it  is  true,  that 
embolism  is  now  to  be  feared,  from  the  washing  off  of  granula- 
tions or  debris  from  about  the  valves;  but  even  if  this  accident 
occurs,  its  effects  are  apt  to  be  transient.  For  embolism  of  some  sort 
is  a  common  feature  of  valvular  disease,  though  rarely  fatal.  And 
while  embolism  of  the  lungs  may  lead  to  temporary  embarrassment 
of  breathing  or  even  to  haemorrhage,  it  is  seldom  fatal,  except  in 
one  of  the  malignant  forms ;  or  when  the  vascular  occlusion  occurs 
at  a  nerve  centre :  and  even  in  this  last  instance,  the  lesion  is  not  ab- 
solutely irremediable.  So  that  when  the  patient  has  reached  the 
second  stage  and  satisfactory  compensation  has  been  established,  he 
needs  no  treatment,  no  matter  how  loud  his  murmur.  Subject  to 
the  limitations  of  his  bodily  condition,  and  his  individual  capacity 
for  work,  he  may  resume  his  former  methods  of  life,  guarding  him- 
self against  danger  by  the  rules  already  laid  down.  And  by  rigid 
adherence  to  them  he  may  live  an  average  life. 

Patients  come  to  me  not  infrequently  in  this  stage  to  take 
a  course  of  carbonated  baths  and  exercises,  but  I  invariably  de- 
cline to  give  them,  simply  because  they  are  unnecessary. 

If,  however,  compensation  breaks,  introducing  the  third  stage, 
prompt  treatment  is  important,  if  life  is  to  be  saved.  Such  early 
symptoms  as  shortness  of  breath  on  overexertion,  difficulty  of  sleep- 
ing in  the  prone  position,  palpitation  and  arrythmia  indicate  that 
danger  is  at  hand.  And  yet  rest  in  bed,  freedom  from  care,  a 
laxative  and  restricted  diet,  with  perhaps  an  anti-fermentative  and 
digestive  tablet  or  powder,  will  usually  give  relief,  certainly  for  a 
time. 

These  incidents  being  noted,  however,  it  is  better  to  institute 
treatment  by  baths  and  exercises,  and  not  wait  for  cyanosis  and 
serous  effusions.  Surely  a  plan  that  will  avoid  appealing  to  vene- 
section, hydrogogues,  and  opiates,  those  "three  firm  friends  more 
sure  than  day  and  night"  to  some  of  our  profession,  merits  very 
serious  consideration.  Besides,  of  all  agencies  at  this  time,  baths 
and  exercises  are  the  most  efficient ;  indeed,  they  enable  us  to  dis- 
pense with  all  the  "three  horrid  sisters,"  as  I  call  them  ;  and  also 
with  drugs  that  are  improperly  used  to  stimulate  the  heart.  In 
addition  to  the  active  and  passive  movements  to  be  employed,  the 
patient  should  be  instructed  to  walk  daily  in  the  open  air,  gradually 
increasing  the  distances ;  but  never  permitted  to  hurry.  In  fact, 
no  form  of  physical  strain  should  be  allowed.     There  is  a  neu- 


The  General  Management  of  Heart  Diseases  223 

rotic  clement  in  almost  all  cases  of  broken  compensation  ;  in   fact, 
in  most  instances  of  dilatati(jn. 

Either  kind  of  strain  may  cause  heart  failure  and  death.  There 
is  also  another  danger,  especially  in  aged  persons.  It  is  their 
tendency  to  bolt  down  unmasticated  food,  or  eat  too  freely  when 
suffering  from  over-fatigue,  or  if  the  digestion  is  weak.  Acute 
indigestion  is  the  result,  with  gaseous  distention  of  the  gastro- 
intestinal tract.  The  extra-cardiac  pressure  produced  in  these  cases 
may,  and  often  does,  kill,  by  interference  with  the  action  of  the 
heart.  The  locality  is  also  to  be  considered.  The  elevation  should 
not  exceed  1,500  to  2,000  feet,  and  the  prevailing  climate  should  be 
mild,  equable  and  dry,  so  that  exercise  can  be  taken  daily  in  the 
open  air.  There  are  few  contraindications  to  the  use  of  baths 
and  exercises  ;  but  patients  with  parenchymatous  nephritis,  or  arterio- 
sclerosis, where  apoplexy  is  threatened ;  diabetics  when  the  amount 
of  sugar  is  large ;  and  phthisical  subjects  are  not  likely  to  be  bene- 
fited, and  are  therefore  improper  subjects  for  this  treatment. 

In  the  subacute  dilatation  of  neurotic  or  ana?mic  young  people, 
especially  those  who  lead  sedentary  lives,  or  have  long  hours  and 
poor  food,  where  carbonated  baths  and  exercises  are  not  available, 
nutrients  like  malt,  iron,  quinine,  arsenic,  and  the  alkaloids  of  nux 
vomica,  help  to  check  dilatation  and  restore  the  heart's  tone.  In 
general,  strychnine  in  1/60  to  1/30  grain  doses,  or  the  milder  bru- 
cine  in  larger  doses,  are  good  nerve  tonics ;  but  contracting  both 
heart  and  arterioles,  they  are  undesirable  for  continuous  use.  Be- 
sides, I  hold  them  to  be  cumulative  in  their  action,  occasionally 
producing  digestive  disturbances.  In  the  debility  of  old  persons  I 
use  arsenic  in  i/ioo  grain  doses,  or  the  arseniate  of  iron  in  1/60 
grain  doses.  I  have  also  used,  in  the  fat  heart,  the  cratcegiis-oxy- 
acantha,  or  hawthorn  berry,  as  a  substitute  for  strychnine,  and  have 
found  it  of  some  utility.  The  American  berry  appears  to  be  the 
best.  The  dose  is  5  to  10  minims  of  the  tincture.  It  is  important 
to  get  a  good  article.  Under  the  same  category  falls  the  cactus,  or 
cereus  grandiflorus  (night-blooming  cereus)  of  Mexico.  It  ap- 
pears to  regulate  by  stimulating  the  vasomotor  centers.  One  to 
two  minims'  of  the  alcoholic  tincture  is  useful  in  myocardial  dis- 
eases. It  appears  to  have  no  cumulative  effect.  Somewhat  similar 
in  action  is  the  suprarenal  extract  given  in  doses  of  i  to  3  grains 
of  the  powder,  in  gelatine  capsules,  three  times  a  day.     It  is  prompt 


°  Dr.  Green,  of  Chicago,  uses  only  1-5  of  a  drop  of  the  alcoholic  tincture. 
Am.  Med.,  Nov.  2,   1901. 


224  The  General  Management  of  Heart  Diseases 

and  cncrg'etic  in  its  action,  which  is  sometimes  felt  in  a  few  sec- 
onds, may  last  three  hours  or  more,  and  has  no  unpleasant  after- 
effects. It  is  essentially  a  heart  stimulant.  Among  cardiac  seda- 
tives I  still  use,  to  a  limited  extent,  ralcriaii,  but  prefer  the  bromide 
of  cine,  given  in  i/io  grain  doses.  Sometimes,  as  already  indi- 
cated, 1  rely  on  the  tincture  of  aeonite  in  2  minim  doses  every  3  or 
4  hours.  While  aconite  is  a  vasomotor  dilator,  it  is  also  a  diuretic, 
to  some  extent,  and  of  course  a  mild  diaphoretic.  It  is  useful  in 
cases  where  digitalis  and  drugs  of  this  group  have  been  used  to  ex- 
cess. It  quiets  the  tumultuous  heart ;  in  the  mildly  neurotic  heart 
I  prefer  to  use  eaiii/^ltor  iitO)iobroi)iati\  especially  in  the  fluttering 
heart  of  emotional  wonaen.  It  is  also  useful  in  nocturnal  palpita- 
tion, such  as  is  so  frequently  seen  in  diabetics  and  in  aortic  disease. 
Another  drug  of  limited  use  in  belladonna.  It  is  helpful  in  5  minim 
doses  of  the  tincture,  given  in  anginoid  attacks  and  arrhythmia.  I 
use  it  chiefly,  however,  as  an  external  application.  In  severe  at- 
tacks of  dyspnoea  I  am  apt  to  give  nitroglycerine  in  doses  of  from 
i/ioo  to  1/25  of  a  grain,  sometimes  giving  the  latter  dose  at  in- 
tervals of  ten  minutes,  until  relief  is  obtained.  While  nitroglycerine 
contracts  the  heart,  it  is  a  vaso-dilator,  and  diminishes  arterial  re- 
sistance, so  that  it  relieves  the  laboring  heart.  As  the  action  of 
the  nitrites  lasts  about  an  hour,  they  should  be  given  at  hourly  in- 
tervals, in  threatened  heart  failure.  In  very  severe  cases  I  give  them 
every  five  minutes  until  relief  is  obtained.  Nitroglycerine  and  the 
nitrites  are  efficient  and  safe  remedies,  and  I  have  never  seen  any 
lasting  bad  effects  from  them,  even  when  I  have  given  very  large 
doses.  In  sudden  and  violent  attacks  I  give  capsules  each  contain- 
ing i/ioo  of  a  grain  of  nitroglycerine,  %  oi  a  grain  of  amyl  nitrite 
and  1/50  of  a  grain  of  menthol,  with  i/ioo  of  a  grain  of  the  oleo- 
resin  of  capsicum.  These  ingredients  are  suspended  in  10  minims  of 
oleum  Ricini.  Relief  is  usually  obtained  in  less  than  a  minute, 
often  in  a  few  seconds.  The  capsule  may  then  be  given  safely  at 
intervals  of  four  hours  for  days  together,  to  prevent  subsequent 
attacks. 

This  combination,  which  is  my  modification  of  an  English  form- 
ula, has  met  wath  a  favorable  reception,  but  it  is  not  very  stable. 
In  fact,  it  is  tmreliable  in  action,  unless  freshly  prepared.  I  never 
use  any  preparation  of  opium  in  chronic  cases.  One  of  the  most 
unfortunate  results  of  the  improper  administration  of  digitalis  and 
its  congeners  is.  that  they  sometimes  produce  such  distressing  re- 
sults, that  patients  take  relief  in  opiates  and  alcoholics.     Nor  is  it 


The  General  Management  of  Heart  Diseases  225 

much  of  an  improvement  on  the  opiates  to  give  chloral  or  its  ana- 
logues, chloralamid,  urethran  and  ameline  hydrate.  They  are  pri- 
marily hypnotics.  If.,  however,  a  hypnotic  drug  is  absolutely  essen- 
tial, I  use  paraldehyde  or  trional.  As  a  rule,  however,  if  a  patient 
has  been  addicted  to  these  drugs,  if  one  substitutes  for  them  a 
course  of  baths  and  exercises,  the  result  will  be  a  revelation ;  for  it 
will  often  be  found  that  they  can  be  dispensed  with,  especially  if 
the  carbonated  bath  is  taken  just  before  bedtime. 

Laxatives  are  essential  in  the  treatment  of  chronic  heart  dis- 
eases. They  should  be  carried  to  the  point  of  producing  at  least  two- 
liquid,  or  semi-solid,  movements  a  day.  For  this  purpose  I  have 
been  in  the  habit  of  using  waters  that  contain  the  sulphate  of  sodium. 
In  place  of  them  I  often  use  a  preparation  which  has  the  effect  of 
a  saline  aperient,  a  hepatic  and  a  diuretic.  It  consists  of  equal  parts 
of  sulphate  of  sodium,  phosphate  of  sodium,  and  the  neutral  tar- 
trate of  sodiiun.  The  dose  is  i  to  2  drachms  dissolved  in  hot 
water,  and  should  be  taken  one  hour  before  breakfast.  I  also  use 
a  hepatic  consisting  of  the  resin  of  podophyllin,  )^  grain ;  extract  of 
colocynth,  i  grain ;  extract  of  hyoscyamus,  i  grain ;  and  extract 
nucis  vom.,  1/6  grain ;  one  pill  to  be  taken  every  other  night.  To 
get  the  best  effects  of  this  combination,  however,  it  should  be  freshly 
made. 

In  some  instances,  especially  after  middle  life,  I  give  small  doses 
of  calomel  as  often  as  twice  a  week,  to  get  the  laxative,  sedative 
and  tonic  effects  of  the  mercurial.  In  arterio-sclerosis  the  iodides 
are  indispensable,  and  in  the  syphilitic  form  mercury  is  equally 
essential.  Some  of  my  patients  take  the  iodides,  wdth  intermis- 
sions, year  in  and  year  out.  I  find  them  especially  suited  for  aortic 
disease.  I  usually  begin  with  5  minims  of  the  saturated  solution 
of  the  iodide  of  sodium,  increasing  the  strength  gradually,  but 
rarely  surpass  10  minims  at  a  dose.  Sometimes  I  find  3  or  4 
minims  enough.      Iodine  in  various  other  forms  may  also  be  used. 

But  satisfactory  treatment  is  almost  always  incomplete  without 
some  medication  directed  to  the  gastro-intestinal  tract,  and  here 
is  a  field  for  the  whole  range  of  digestives  and  anti-fermentatives. 
Unfortunately  there  is  more  empiricism  necessar}-  to  meet  the  indi- 
cations here,  than  in  any  other  phase  of  cardiac  disease,  and  much 
ingenuity  is  often  required  to  devise  the  precise  formula  required; 
but  success  will  be  the  reward  of  patience.  In  case  of  overweight, 
great  help  is  obtained  from  a  strict  dietary.  I  have  devised  the  fol-. 
lowing  one,  and  have  used  it  with  success. 


226  The  General  Management  of  Heart  Diseases 

8  A.M.,  breakfast.  3  ounces  cold  meat  witluuit  lal ;  1  ounce 
gluten  or  whole  wheat  bread  ;  a  cup  of  postuni  with  milk,  or  lemon- 
ade. 

10:30  A.M..  a  cuj)  of  beef  tea. 

1  1\M..  5  ounces  of  lean  meat  or  hsh ;  salad  with  I'Yench 
dressing. 

3:30  P.M..  8  ounces  of  milk  and  vicliy  (half  and  lialf). 

6  P.M..  3  ounces  of  rare  meat  or  hsh.  with  pickles  and  salad;  I 
ounce  Graham  bread  ;  stewed  fruit. 

8:30  P.M.,  8  ounces  of  milk  and  vichy  water  (half  and  half). 
Vichy  or  plain  water  may  be  taken  as  desired  during  the  day. 

This  is  not  a  severe  dietary,  as  compared  with  some  that  are 
used. 

As  a  rule,  I  use  digitalis  only  when  special  complications  arise — 
•as,  for  exam])le.  when  I  am  confronted  with  urinary  suppression, 
•its  attendants  or  sequelae,  and  where  prompt  effects  are  important. 
The  more  I  see  of  heart  disease,  the  more  I  am  convinced  that 
ordinary  digitalis  is  not  only  of  uncertain  composition,  but  unre- 
liable, and  therefore  a  dangerous  remedy ;  especially  if  it  is  to  be 
used  indiscriminately.  It  may  produce  spasms  of  both  heart  and 
vessels.  In  fatty  hearts,  I  hold  it  to  be  particularly  dangerous, 
and  even  in  urinary  suppression,  in  our  attempts  to  get  its  diuretic 
effect,  we  may  cause  fatal  cardiac  contraction.  Digitalis  and  its 
derivatives  are  slow,  requiring  some  hours  before  their  physio- 
logical action  is  obtained  :  therefore,  we  cannot  depend  upon  them 
in  emergencies.  If  given  as  a  diuretic,  digitalis  may  be  advan- 
tageously combined  with  20  grains  of  a  bitartrate,  and  given  at  in- 
tervals of  four  hours.  Digitoxine  is  now  generally  admitted  to  be 
more  uncertain  in  action  than  digitalis,  and  I  avoid  it.  Merck's 
digitaline  in  my  hands,  however,  has  always  proved  satisfactory. 

Digitalis,  however,  has  a  distinct  field  in  mitral  diseases  where 
the  pulse  is  irregular,  and  where  there  is  renal  insufficiency  with 
or  without  dropsy.  It  steadies  the  pulse,  slows  it,  makes  it  firmer ; 
and  stimulates  the  capillary  circulation,  which  is  the  ultimate  ob- 
ject to  be  attained.  Favorable  action  is  heralded  by  increase  in 
the  urine.  If  it  acts  badly,  the  signs  of  warning  are  nausea  or 
vomiting,  a  small  and  irregular  pulse,  embarrassed  respiration,  and 
diminution  of  urine. 

When  a  standardized  preparation  of  digitalis^  cannot  be  ob- 
tained, it  is  best  to  use  powdered  leaves  in  doses  of  2  to  5  grains 


•  Such  as  has  been  made  by  Parke,  Davis  &  Co. 


The  General  Management  of  Heart  Diseases  227 

several  times  a  day.  A  small  number  of  persons  can  take  digi- 
talis with  intermissions  for  long  periods  of  time  with  benefit.  But 
these  cases  are  exceptional,  and  do  not  disprove  the  rule.  The 
African  strophanthus  is,  in  a  measure,  a  fair  substitute  for  digi- 
talis, though  the  two  have  somewhat  dissimilar  physiological  effects. 
As  a  heart  compressor,  I  hold  that  strophanthus  acts  more  power- 
fully than  digitalis,  but  as  an  arterial  compressor  it  has  less  power. 
It  slows  the  heart  beat,  shortens  systole,  and  lengthens  diastole ; 
unlike  digitalis,  it  is  not  much  of  a  diuretic  and  is  not  cumulative ; 
unfortunately  it  is  apt  to  produce  diarrhoea  and  nervous  irritability. 
It  is  well  to  begin  with  small  doses,  say  3  minims  of  the  tincture, 
gradually  increasing  them  and  noting  the  effect  of  the  drug.  It 
should  not  be  long  continued,  however,  and  must  always  be  ad- 
ministered cautiously.  It  acts  more  promptly  than  digitalis,  and 
herein  is  its  great  advantage. 

Convallaria  majalis,  the  lily  of  the  valley,  also  belongs  to  the 
digitalis  group.  It  slows  the  heart,  and  is  a  diuretic  without  cumu- 
lative action,  but  in  small  doses  it  is  an  emetic  and  purges  actively, 
like  jalap  or  scammony.  In  mild  forms  of  cardiac  disease  it  has 
no  place,  but  when  cardiac  stimulation,  with  mild  diuresis  and 
catharsis,  is  needed,  convallaria  is  applicable.  There  are  com- 
paratively few  instances,  however,  in  which  it  is  indicated.  The 
standardized  drug  should  be  used  exclusively.  In  adonis,  from 
the  adonis  vernalis,  or  false  hellebore,  we  have~-a;  drug  whose  glu- 
coside  adonidme  is  allied  to  digitaline.  It  slows  the  pulse,  increases 
its  force,  and  is  a  diuretic  without  cumulative  action.  It  is  useless 
in  functional  disorders,  but  is  a  fair  substitute  for  digitalis,  as  a 
heart  stimulant.  The  initial  dose  of  3  minims  may  be  gradually 
increased.  The  adonis  vernalis  is  sometimes  confounded,  as  it 
should  not  be,  with  the  adonis  cBstivalis,  which  appears  to  have  no 
value  as  a  heart  stimulant,  and  whose  dose  is  three  or  four  times 
that  of  the  adonis  vernalis.  Too  much  reliance  should  not  be  put  on 
caffeine,  which  is  not  always  made  from  coffee — sometimes  from 
ordinary  tea,  guarana  or  the  kola  nut ;  the  citrate,  a  favorite  form, 
contains  only  50  per  cent,  of  caffeine.  Primarily,  caffeine  produces 
cardiac  contraction,  leading,  in  large  doses,  and  with  some  persons,  to 
spasm  and  even  paralysis.  Secondarily,  its  effects  are  depressing ; 
while  it  has  proved  an  uncertain  diuretic  in  my  hands. 
"^  Sparteine  from  the  tops  of  the  scoparius^  or  broom,  increases 
blood  pressure,  slows  the  heart,  but  is  unreliable.  Its  action  is 
chiefly  upon  the  heart  muscle.      I  have  found  it  a  fairly  good  diu- 


228  The  General  Management  of  Heart  Diseases 

retic  and  heart  stimulant  for  cardiac  dropsy,  in  doses  of  1/20  to  i/io 
of  a  grain.  Diurctinc,  the  sodium  salicylate  of  theobromine,  is 
something  of  a  diuretic.  I  have  used  it  in  15  grain  doses.  Apocy- 
num,  the  Caiyidian  hemp,  1  have  found  of  some  value  in  dropsy, 
as  it  is  a  diuretic  and  a  cathartic.  It  should  be  distinguished  from 
Indian  hemp  or  cannabis  indica.  Half  a  grain  of  powdered  apocy- 
num  may  be  given  at  dose.  In  cardiac  oedema  I  have 
been  most  favorably  impressed  by  the  muriate  of  pylocarpinc,  which 
I  have  given  in  divided  doses  to  the  extent  of  nearly  2  grains  in  a 
day,  carefully  watching  its  effects  and  guarding  them  by  stimu- 
lants ;  and  I  have  had  no  unfavorable  experience  with  it. 

As  a  rule,  it  is  best  to  use  single  remedies,  rather  than  combi- 
nations. Otherwise,  if  the  combination  has  no  good  effects,  we  are 
forced  to  discontinue  it,  and  to  throw  discredit  on  all  the  ingre- 
dients while  one  of  them  may  be  the  very  one  we  need. 

If  oedema  of  the  lower  extremities  is  not  relieved  by  these  reme- 
dies, massage  may  be  effectual.  If  it  fails,  the  skin  of  the  legs  may 
be  punctured  with  an  ordinary  cambric  or  triangular  needle.  In 
uncomplicated  cases  no  further  operative  procedures  are  desirable. 
From  the  foregoing  recital,  it  is  seen  that  we  have  a  large  num- 
ber of  simple  drugs  that  are  available  in  heart  diseases.  By  a 
judicious  selection  or  combination  of  them,  aided  by  baths,  exer- 
cises, diet  and  other  agencies,  we  can  usually  treat  our  patients 
successfully  without  resorting  to  any  of  the  digitalis  group ;  or  at 
least  we  need  not  call  upon  them  except  under  very  special  condi- 
tions. Digitalis  has  powerful  defenders,  such  as  Huchard  and 
Broadbent.  But  the  digitalis  we  buy  in  this  country  is  apt  to  be 
of  uncertain  composition.  If  druggists  substitute  the  seeds  for 
the  leaves,  light  is  thrown  on  the  matter.  Then  different  prepara- 
tions have  different  effects.      For  example,  according  to   Porter,* 

*W.  H.  Porter, 
the  infusion  has  a  different  effect  from  the  tincture,  because  in  the  in- 
fusion the  active  principles,  digitoxine  and  digitaline,  are  barely 
soluble  in  water ;  while  digitaleine  and  digitonine,  two  others  of  the 
five  active  principles  which  are  soluble  in  water,  antagonize  one 
another.  Hence  the  infusion  is  comparatively  weak.  But  in  the 
tincture  both  the  digitoxine  and  digitaline  are  soluble  in  alcohol,  as 
also  the  digitonine ;  while  the  digitaleine  (nearly  as  soluble)  is  also 
present.  Hence  the  tincture  is  comparatively  strong. 
— -.  In  Germany  this  difificulty  is  met  by  the  use  of  the  pow- 
dered leaves,  as  my  friend.  Dr.  Groedel,  of  Nauheim,  advises. 
He  begins  with  four,  or  even  eight,  grains  of  the  powdered  leaves, 


The  General  Management  of  Heart  Diseases  229 

given  in  divided  doses  for  a  single  day.  Jf  no  harm  ensues,  he  gives 
still  larger  doses  on  the  third  day,  and  continues  the  treat- 
ment for  several  days.  And  he  is  able  by  this  plan  to 
give  it,  in  many  instances,  where  other  methods,  such  as  those  by 
baths  and  exercises,  are  unavailable.  Even  if  he  finds  there  is 
at  first  a  bad  efifect,  he  returns  to  the  digitalis,  after  an  in- 
terval, and  gives  it  a  further  trial.  Some  of  his  patients  take  digi- 
talis continuously  for  months  at  a  time.  I  have  never  had  occasion 
to  prescribe  digitalis  continuously,  how^ever,  using  usually  the  ni- 
trites instead.  As  a  matter  of  fact,  in  ordinary  cardiac  failure  I 
am  disposed  to  treat  everything  but  the  heart.  If  one  treats  the 
associated  conditions,  he  will  not  be  so  often  called  on  to  use  heart 
stimulants.  Many  mild  chronic  cases  of  broken  compensation,  or 
heart  weakness,  improve  at  once  after  a  restricted  diet  and  moderate 
exercise. 

In  persons  of  middle  life  it  is  too  much  the  habit  to  "overeat." 
The  rule,  "always  to  rise  from  the  table  with  an  appetite,"  is  pecu- 
liarly important  for  these  persons ;  for  with  them  acute  attacks  of 
indigestion  are  serious  matters. 

It  is  a  little  difficult  to  know  just  what  exercise  to  prescribe  for 
people  with  well-ordered  compensation.  Usually  horseback  exercise 
is  permissible ;  occasionally  it  is  not.  Most  people  may  ride  a  wheel 
"on  the  flat,"  but  they  should  not  attempt  high  hills.  Walking  is 
good.  Usually  I  make  my  patients  walk  at  least  two  miles  a  day. 
Another  point  is  of  importance.  In  ordinary  cases  of  broken  com- 
pensation, very  small  doses  at  comparatively  short  intervals  are 
more  effective  than  larger  doses  at  longer  intervals.  Furthermore, 
when  it  is  necessary  to  give  large  doses  of  any  drug,  in  attacks  of 
heart  failure,  it  is  important  to  gradually  reduce  the  dose,  and 
lengthen  the  interval,  just  as  soon  as  there  is  a  proper  response  to 
the  action  of  the  drug. 


Chapter  XX. 

NAUHEIM   ^FETHODS   IN   CHRONIC  HEART  DISEASES 
WITH    AMERICAN   ADAPTATIONS.^ 

Successful  practice  of  the  Nauheim  system  in  chronic  heart  dis- 
eases includes  the  use  of  carbonated  brine  baths,  resistance  exer- 
cises and  massage ;  while  the  diet  and  general  health  of  the  patient 
have  to  be  regulated.  It  follows,  therefore,  that  this  method  re- 
quires the  immediate  supervision  of  a  physician,  and  that  no  mas- 
seur or  operator,  however  skilled  in  his  branch,  can  be  competent 
to  employ  it,  independently  of  a  physician,  even  if  permitted  to  do 
so  by  our  State  laws. 

While  the  advantages  of  carbonic  acid  gas  as  a  therapeutic  agent 
are  generally  known,  a  method  of  using  the  dry  gas  has  been 
brought  before  the  profession  in  this  country  by  Dr.  A.  Rose,  of 
New  York,  and  successes  with  it  have  been  reported  in  neuralgias, 
pareses,  rheumatism,  amenorrhoea,  indolent  ulcers,  catarrh,  etc. 

Though  it  has  been  used  in  many  of  the  prominent  bathing 
resorts  lor  a  long  time,  the  application  of  it  in  chronic  heart  dis- 
eases has  been  a  more  recent  afifair.  In  fact,  so  far  as  we  know  at 
present,  it  appears  to  have  originated  with  Beneke,  who  at  one 
time  practiced  medicine  in  Nauheim.  But  his  claims  were  modest, 
for  in  his  time  the  waters  w^ere  chiefly  used  for  gout  and  rheuma- 
tism. Later  Oertel,  a  physician  who  also  practiced  in  Nauheim, 
elaborated  a  system  that  combined  baths,  massage  and  graduated 
hill-climbing.  This  method  came  to  be  known  as  the  Terrain  Cur. 
After  Oertel's  death,  however,  his  method  fell  into  comparative 
disfavor.  Finally,  August  Schott,  while  treating  neurasthenics 
by  the  Ling  system  of  resistance  movements,  found  that  they  stimu- 
lated the  heart,  and  w'ith  it  the  general  circulation.  Hence  the 
origin  of  the  Sckott  system. 

To-day  the  methods  employed  at  Nauheim  are  mainly  the  elab- 
oration of  the  work  of  these  three  men,  though  the  present  physi- 
cians of  this  locality,  such  as  Groedel,  Theodor  Schott  and  others, 
have  added  much  to  the  details  of  the  methods,  while  their  large 
experience  has  qualified  them  to  define  its  limitations. 

For  particulars  as  to  further  details  of  the  methods  employed 


'  Originally  published  in   Intcrnat.   Clinics.  Vol.   I,  ser.   13. 
Feb.  1904. 


Nauheim  Methods  with  American  Adaptations  231 

at  Nauheim,  the  reader  is  referred  to  the  numerous  articles  that 
have  been  written  on  this  subject,  and  especially  to  the  papers  of 
Dr.  W.  C.  Rives  {Nezv  York  Med.  Jour.,  1896,  LXIV,  pp.  471-479) 
and  Dr.  Victor  Neesen  (Netv  York  Med.  Jour.,  March  10,1900). 
Both  of  these  physicians  have  enjoyed  the  unusual  advantages  of 
assisting-  in  the  treatment  of  heart  diseases  at  Nauheim,  and  later,  of 
practicing  these  methods  in  this  country. 

In  the  year  1897,-  I  began  to  apply  the  Nauheim  system  in 
chronic  heart  diseases,  using  liquid  gas  and  following  out  Nauheim 
methods  as  well  as  I  could,  but  I  found  it  impossible  to  transplant 
the  system  bodily  to  this  country.  Modifications  to  suit  our  altered 
conditions  were  necessary,  and  I  purpose  in  the  following  pages  to 
detail  the  adaptations  made.  In  the  first  place,  after  a  few  months' 
trial  of  liquid  gas,  I  abandoned  it  for  reasons  that  need  not  be 
detailed  here,  and  began  generating  the  gas  by  the  combined  use  of 
an  acid  sodium  sulphate  and  the  bicarbonate.  This  was  merely  an 
adaptation  of  the  Hamburg  method,  known  as  Sandow's.  I  have 
generated  gas  in  these  two  ways  for  over  eight  years,  and  thus 
far  without  any  accidents  or  bad  results.  During  this  period  car- 
bonated brine  baths  have  come  to  be  used  extensively  in  typhoid 
fever,  also  in  neurasthenic  states,  lithsemia  and  various  other  affec- 
tions,^ and  the  sphere  of  their  utility  is  being  gradually  extended.* 
My  experiences,  however,  have  enabled  me  to  define  in  my  own 
mind  with  tolerable  accuracy  both  the  scope  and  the  limitations  of 
the  system,  so  far  as  heart  diseases  are  concerned.  I  cannot  preface 
what  I  am  about  to  write  with  anything  better  than  the  following 
sentences :  Successful  application  of  the  Nauheim  system  requires 
the  closest  attention  to  details.  Disregard  of  them  means  failure. 
The  largest  success  comes  from  the  most  careful  attention  to  each 
apparently  insignificant  feature. 

My  methods  are  as  follows :  T  use  mainly,  as  I  have  always 
done,  resistance  exercises ;  by  which  I  mean  exercises  where  the 
patient  makes  voluntary  movements  that  are  resisted  by  the  operator. 
These  movements  are  quite  gentle,  and  there  are  intermissions  be- 
tween them.  Tf  there  should  be  any  w^eariness  on  the  part  of  the 
patient,  or  if  his  breathing  becomes  rapid  or  the  pulse  rises,  a  pro- 


"  On  Jan.  28.  1897.  I  read  a  paper  on  this  subject  before  the  Med.  See. 
of  the  State  of  New  York. 

'  See  Reports  by  Putnam  and  Fitz.  Boston  Medical  and  Surgical  Journal, 
March  13,  1902 :  and  S.  Baruch,  Medical  Record.  Tanuar\-  10.  1901. 

*  The  experiments  of  numerous  observers  have  demonstrated  not  only  that 
contraction  of  the  heart  usually  follows  the  baths,  but  that  the  cardiac  a^Hon 
is  made  less  frequent,  more  reg^ular  and  stronger.  (See  Camac  in  Johns  Hop- 
kins Bulletin.  Feb..  IQ04.')  I  have  verified  these  facts  manv  times  by  the  use 
of  Cook's  modification  of  the  Riva  Rocci  sphygmanometer. 


232  Nauheim  Methods  with  American  Adaptations 

longed  intermission  is  given,  until  the  equilibrium  of  respiration  or 
pulse  is  regained.  There  should  always  be,  however,  an  intermis- 
sion of  at  least  one  minute  between  each  exercise  of  the  series.  The 
operator  uses  both  hands,  one  supporting  the  part  being  exercised, 
whatever  it  may  be,  the  other  resisting  the  movement  gently,  but 
firmly.  But  the  operator's  hands  in  resisting  should  grasp  the 
limb  or  trunk  or  heatl  with  only  sufficient  force  to  steady  it  during 
the  required  resistance.  At  the  end  of  each  movement  the  part 
is  restored  to  its  natural  position.  The  resistance  should,  in  every 
case,  be  graduated  to  the  patient's  strength,  and  it  is  here  that  the 
experience  of  the  operator  conies  into  play — for  his  trained  hands 
easily  recognize  the  amount  of  the  patient's  strength,  as  soon  as  the 
latter  begins  the  execution  of  a  movement. 

During  the  entire  seance  the  patient  shmild  breathe  naturally. 
As  a  rule,  each  muscle  is  made  to  do  its  work  with  a  gradually  in- 
creasing force,  from  the  beginning  to  the  end  of  the  course. 

The  movements  themselves  are  flexion,  extension,  adduction, 
abduction,  and  rotation  of  the  limbs,  neck  and  trunk.  The  object 
of  the  exercises  is  to  improve  the  action  of  the  heart  and  general 
circulation.  The  following  is  the  general  outline  for  the  first  two 
weeks  of  an  ordinary  course:  I  begin  with  the  passiz'e,  that  is, 
unresisted  movements,  such  as  I  introduced  in  1898.  They  are 
useful  in  all  cases,  but  especially  in  any  form  of  embarrassed  respira- 
tion, and  are,  in  effect,  the  movements  of  artificial  respiration. 

In  one  variety  adapted  for  women  and  stout  persons  the  patient 
lies  on  the  back  with  the  head  a  little  elevated  (Fig.  25).  The  oper- 
ator then  stands  at  the  patient's  side  and,  passing  his  two  hands 
beneath  the  chest,  raises  it  slowly  and  gently,  as  far  as  it  will  go 
without  lifting  the  patient  off  the  couch  or  bed.  The  patient  should 
aid  the  operator  as  far  as  possible  by  making  his  respiration  coin- 
cide with  the  movements  of  the  operator.  One  or  two  natural 
respiratory  efforts  should  take  place  after  each  artificial  move- 
ment. From  8  to  16  are  the  limits  in  the  two  minutes  devoted  to 
this  exercise.  Then  the  chest  is  allowed  gradually  to  return  to  its 
normal  position.  With  very  obese  persons  two  operators  may  be 
required.  With  a  folded  sheet  passed  under  the  back,  and  each 
operator  grasping  an  end,  the  procedure  can  be  employed  with  ease. 
It  is  called  ''chesl  raisin!^,"  in  distinction  from  the  next-named 
exercise. 

The  second  respiratory  movement,  which  is  suited  for  children 
and   persons   of   slight   build,   is   shown    in    Fig.    26.     It   is   called 


X 


^ 


w 


•^x 


"  c 
t;0 


M  C 


1^ 


ti. 


Plh 


Nauheim  Methods  with  American  Adaptations  233 

'' shoulder  raising."  Tlic  patient  sits  on  a  stool  while  the  operator 
stands  on  another  behind  him.  The  operator  passes  his  hands 
over  the  patient's  shoulders  in  front  and  grasps  him  by  his  arm- 
pits ;  he  then  lifts  the  patient's  shoulders  upwards  as  far  as  they 
will  go  without  his  being  raised  from  the  stool,  the  patient  offer- 
ing no  resistance.  As  in  "chest  raising,"  the  patient  should  aid 
the  operator  slightly  by  making  his  respiration  coincide  with  the 
artificial  movements  of  the  operator.  One  or  even  two  natural 
respirations  should  be  made  after  each  artificial  movement. 
From  8  to  16  should  be  the  limit  of  the  artificial  movements,  in 
the  two  minutes  devoted  to  this  exercise.  After  each  movement, 
whether  passive  or  resisted,  massage,  percussion,  or  vibration  is 
given  first  to  the  extremities  and  then  to  the  trunk,  the  foot  and 
leg  being  first  massaged  ;  later  the  hand  and  forearm. 

The  first  resistance  movement  following,  after  an  interval  of  a 
minute  is  forearm  flexion  and  extension  (Fig.  27).  The  arm  of  the 
patient  is  supported  by  one  hand  of  the  operator  applied  above  the 
elbow,  while  the  other  rests  lightly  on  the  patient's  hand.  The 
patient  now  fiexes  the  forearm  on  the  arm  to  the  extreme  limit,  the 
operator  gently  resisting.  Then  the  arm  is  returned  Hghtly  to  its 
place  by  the  operator. 

Extension  is  begun  when  the  forearm  is  flexed,  after  the  cus- 
tomary interval.  The  operator  still  supporting  the  arm  above  the 
elbow,  grasps  the  wrists  lightly  and  resists,  while  the  patient  ex- 
tends the  arm,  carrying  his  hand  down  to  the  naturally  dependent 
position.  Then  follow  hand  and  forearm  massage,  which  should 
be  light,  and  not  prolonged  more  than  two  minutes.  The  next  re- 
sistance movements  are  leg  and  thigh  flexion  and  extension.  (Figs. 
28  and  29).  The  leg  is  first  extended  forward  by  the  patient  and 
then  returned  to  its  original  position,  and  after  the  intermission 
carried  backward.  Resistance  is  given  in  each  case  by  the  operator 
pressing  the  open  hand  against  the  lower  part  of  the  limb.  Slight 
massage  of  the  shoulder  and  arm,  for  two  minutes,  follows. 

The  next  resistance  movements  are  thigh  flexion  and  extension 
(Figs.  30-31).  To  give  this  movement  properly  the  patient  should 
sit  on  a  chair  or  lounge,  with  his  neck  firmly  supported  in  som.e 
way.  This  position  is  not  only  comfortable  for  the  patient,  but 
it  enables  the  operator  to  use  a  little  more  resistance,  than  \vould 
otherwise  be  deemed  advisable,  without  disturbing  the  heart's  action. 
During  any  exercise  the  patient  should,  if  possible,  support  him- 
self by  resting  his  hand  on  a  chair  or  some  other  firm  object. 


234  Nauheim  Methods  with  American  Adaptations 

Then  follows  lii^ht  chest  percussion  or  flagellation  with  the  tip 
of  the  fingers.  This  movement  is  particularly  useful  in  chronic 
heart  disease.  It  appears  to  aid  in  contracting  the  heart" — stimu- 
lating the  respiratory  centers  through  the  cutaneous  nerves. 

The  next  movements  are  tnoik  flexion  and  extension  (  Figs.  31 
and  ^2).  The  patient,  placed  with  his  back  against  the  wall  and  his- 
feet  standing  out  some  seven  or  eight  inches,  bends  his  body  for- 
ward, the  operator  resisting  with  one  hand  over  each  shoulder- joint. 
When  the  body  is  bent  over  to  form  an  angle  of  about  forty-five 
degrees  witli  the  wall,  the  patient  erects  or  extends  himself,  the 
operator  now  resisting  with  his  hands  over  the  scapukie. 

The  course  is  concluded  by  massage  of  the  thigh  and  back. 
To  each  of  the  exercises  in  this  schedule  two  minutes  are  allowed, 
with  intervals  of  one  minute  each,  so  that  the  length  of  the  entire 
seance  is  under  thirty  minutes.  This  scheme  is  applicable  for  the 
first  two  weeks  in  ordinary  cases,  and  is  known  in  my  system  as- 
Scheme  No.  i.     The  following  is  a  brief  outline  of  it: 

Scheme  No.  i. 

1.  Chest  lifting — lying  or  sitting  2  minutes. 

Intermission    i       " 

2.  Foot  and  leg  massage  2      " 

Intermission    i       " 

3.  Forearm  flexion  and  extension 2       " 

Intermission    i       " 

4.  Hand  and  forearm  massage   2       " 

Intermission    i       " 

5.  Leg  and  tliigh  flexion  and  extension   2       " 

Intermission    i       " 

6.  .Arm  and  shoulder  massage   2      " 

Intermission i       " 

7.  Thigh  flexion  and  extension  2      " 

Intermission    i       " 

8.  Chest  percussion   ; 2       "' 

Intermission    I 

9.  Trunk  flexion  and  extension    2 

Intermission    i       " 

10.  Thigh  and  back  massage    2 

Total   length  of  seance    29  minutes. 

During  the  second  and  third  weeks  the  number  of  exercises 
remains  the  same,  but  a  new  group  of  muscles  is  exercised,  and  the 
duration  of  each   exercise  is  lengthened. 

The  course  begins  with  chest-lifting,  foot  and  leg  massage, 
forearm  flexion  and  extension,  and  hand  and  forearm  massage,  but 
in  ])lace  of  leg  extension  there  is  leg  abduction  and  adduction — 
more  difficult  movements  (Figs.  33  and  34).  The  illustrations 
show  how  each  movement  is  made  by  the  patient  and  how  it  is 

"Abrams.  Med.  Rcc,  Jan.  5,  1901. 


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Nauheim  Methods  with  American  Adaptations  235 

resisted  by  the  operator,  who,  in  each  case,  resists  with  the  open 
hand  pressed  against  the  lower  part  of  the  leg. 

Then  after  arm  and  shoulder  massage,  comes,  in  place  of  the 
trunk  flexion  of  Scheme  No.  i,  trunk  rotation.  The  method  is  as 
follows : 

The  operator,  standing  close  to  the  patient,  whose  feet  are 
firmly  fixed,  grasps  one  shoulder  with  each  hand  and  assists  the 
patient  to  turn  his  body  about,  on  its  vertical  axis,  as  far  as  possible 
(Fig.  35).  Then  the  patient  untwists  and  retwists  himself  until  he 
has  turned  around  equally  far  in  the  opposite  direction.  Then  the 
patient  slowly  assumes  his  natural  attitude. 

Chest  percussion  is  then  followed  by  arm  separation,  "the  swim- 
ming exercise"  (Figs.  36  and  37).  The  patient,  holding  his  wrists 
parallel,  carries  them  backward  until  in  line,  the  operator  resisting, 
after  which  the  latter  returns  them  easily  to  their  original  position. 
It  is  not  desirable  to  carry  the  arm  forward  with  resistance,  because 
such  a  movement  would  fix  the  chest,  through  the  action  of  the 
pectoral  muscles,  thus  interfering  with  natural  respiration.  During 
this  exercise  the  patient  may  sit,  stand,  or  lie  down.  If  he  stands, 
he  should  brace  himself  slightly  by  putting  one  foot  forward.  This 
series  ends,  as  in  scheme  No.  i,  with  thigh  and  hack  massage. 

The  following  is  a  brief  epitome  of 

Scheme  'No.  2. 

1.  Chest  lifting — lying  or  sitting 2  minutes. 

Intermission    i 

2.  Foot  and  leg  massage 2 

Intermission    i 

3.  Forearm  flexion  and  extension    2 

Intermission    i 

4.  Hand  and  forearm  massage 2 

Intermission    i 

5.  Leg  abduction  and  adduction  3 

Intermission i 

6.  Arm  and  shoulder  massage   2 

Intermission    i 

7.  Trunk  rotation   3 

Intermission    i 

8.  Chest  percussion 2 

Intermission    i 

9.  Arm  separation   3 

Intermission    i 

10.  Thigh  and  back  massage 3 


Total   duration  of  seance    ■ -ZZ  minutes. 

In  Scheme  No.  2  each  of  the  resistance  exercises  consumes  2  to  3 
minutes  and  some  newer  groups  of  muscles  are  involved. 

In  Scheme  No.  3,  which  is  applicable  for  the  fifth  and  sixth 
weeks,  a  further  change  in  the  series  is  made,  so  far  as  the  resistance 


236  Nauheim  Methods  with  American  Adaptations 

movements  are  concerned,  and  some  new  ones  are  introduced  that 
might  not  be  well  borne  in  the  beginning-  of  the  course — two  par- 
ticularly, "qitarter-circliiig"  and  "head  rotation." 

Scheme  Xo.  3  is  as  follows:  After  the  chest  lifting,  and  foot 
and  leg  massage  comes  "quarter-circling"  (Fig.  38).  The  patient 
sits  on  a  stool,  the  operator  behind  him  with  one  hand  on  the 
patient's  shoulder  in  order  to  fix  it.  the  fingers  of  the  other  hand 
lightly  grasping  the  wrist.  The  patient's  arm  being  extended  down- 
ward, it  is  carried  first  upward  and  forward,  then  downward  and 
backward  over  a  quarter  of  a  circle,  the  operator  resisting.  Then, 
after  the  regulation  hand  and  forearm  massage,  comes  rotation  of 
the  head  on  the  neck.  or.  if  this  cannot  be  well  borne,  simple  flexion 
of  the  head  on  the  neck.  Then  follow  arm  and  shoulder  massage, 
trunk  twisting,  and  chest  percussion,  the  last  resistance  exercise 
being  lateral  Hexion  of  the  trunk  (Fig.  39).  The  trunk  is  simply 
bent  on  the  pelvis  laterally,  the  operator  standing  in  front  of  the 
patient  and  facing  him.  resisting  him  as  he  bends  his  body  well  over 
to  one  side.  One  hand  of  the  operator  rests  on  the  ribs  beneath 
the  axilla,  the  other  on  the  opposite  hip.  The  trunk  having  thus 
been  placed  in  a  position  of  extreme  flexion  the  patient  attempts  to 
straighten  himself  and  carry  his  body  over  to  the  other  side  in 
extreme  lateral  flexion.  This  whole  movement  from  extreme  flexion 
on  one  side  to  extreme  flexion  on  the  other,  is  resisted  by  the  opera- 
tor. Bv  reversing  this  exercise,  there  is  another  movement,  the 
operator  of  course  reversing  the  position  of  his  hands.  This  series 
ends  as  usual  with  thigh  and  back  massage.    In  brief,  it  is  as  follows : 

Scheme  No.  3. 

1.  Chest  lifting— lying  or  sitting  2  minutes. 

Intermission    i 

2.  Foot  and  leg  massage  2 

Intermission    I 

3.  Quarter-circling  forward  and  backward    4 

Intennission    i 

4.  Hand  and  forearm  massage   2 

Intermission    i 

5.  Head  rotation  or  flexion    3      " 

Intermission    i 

6.  Arm  and  shoulder  massage  2      " 

Intermission    i 

7.  Trunk    Twisting    4      ]' 

Intermission    I 

8.  Chest  percussion    2      " 

Intermission    i       ^] 

9.  Trunk  flexion   (laterally)    4      " 

Intermission    i 

10.  Thigh  and  back  massage   3 

Total  duration  of  seance    37  minutes. 


y. 


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U. 


Nauheim  Methods  with  American  Adaptations  237 

It  will  be  noticed  that  in  the  final  series  the  exercises  involve 
newer  and  larger  groups  of  muscles,  and  that  all  of  the  great  muscles 
of  the  body  have  been  exercised.  The  total  duration  of  the  seance 
is  also  longer  and  it  is  intended  that  more  force  should  be  applied. 

By  adopting  a  course  such  as  I  have  outlined,  success  will  be 
attained  in  appropriate  cases.  Failure  in  carrying  out  this  part  of 
the  treatment  is  usually  due  to  carelessness  in  the  selection  of  opera- 
tors, for  on  them  success  is  dependent.  This  topic  has  been  well 
placed  before  the  profession  by  Dr.  Victor  Neesen."  Indeed,  unless 
operators  have  had  special  training  in  this  branch  of  their  work, 
success  is  hardly  to  be  expected,  for  the  method  is  a  peculiar  one. 
Following  the  Swedish  system,  many  operators  are  too  rapid  in  their 
movements.  Others  fail  to  observe  the  required  intermissions. 
Some  are  over-persuaded  by  their  patients,  and  allow  them  to  exert 
undue  force.  Others  fail  to  make  the  patient  breathe  naturally. 
Others  blindly  follow  cast-iron  rules,  even  where  it  is  plainly  ap- 
parent that  from  some  idosyncrasy,  or  temporary  disability,  the  pa- 
tient cannot  follow  the  rules,  in  every  particular.  Perhaps  the  most 
common  and  worst  fault  is  that  undue  force  is  used  in  massage ;  or 
the  operator  disregards  the  rule  that  heart  cases  should  have  no 
abdominal  massage,  unless  it  is  expressly  ordered  by  the  physician. 
It  has  therefore  been  a  public  benefit  that  the  attempts  of  masseurs 
to  practise  the  Nauheim  treatment,  without  medical  supervision,  has 
been  a  failure,  in  this  city  at  least. 
"  Fundamental  rules  for  the  operator  are : 

1.  Perform  each  movement  slowly,  steadily,  and  gently. 

2.  Each  single  movement  is  to  be  followed  by  a  distinct  inter- 
mission, in  which  there  is  entire  relaxation  of  the  patient's  muscles. 
It  is  a  good  plan  to  have  the  patient  rest4iimself  in  a  chair  after 
each  movement  or  series  of  movements.  Double  movements  should 
be  followed  by  longer  intermissions.  In  the  intermission  between 
the  single  or  double  movements,  the  operator  should  take  the  pulse 
and  respirations  and  record  them  on  a  slip  prepared  for  the  purpose. 

3.  Movements  of  the  arm  should  alternate  with  those  of  the  leg 
or  body. 

4.  No  part  of  the  body  should  be  held  so  tightly  as  to  compress 
the  blood  vessels. 

5.  The  patient  should  be  made  to  breathe  naturally  during  the 
seance. 

6.  The  operator  should  be  on  the  watch  for  irregular  breathing, 


"New  York  Medical  Journal,  May  18,  1901. 


23S  Nauheim  Methods  with  American  Adaptations 

pallor,  or  bluciiess  of  the  lips  or  face,  or  any  sign  of  personal  dis- 
comfort or  disturbance  on  the  part  of  the  patient.  Upon  the  advent 
of  any  of  these  signs  the  exercises  must  be  suspended,  for  they 
indicate  that  there  has  been  too  much  resistance,  or  that  the  move- 
ments have  been  too  rapid,  or  the  intermissions  too  short. 

7.  In  the  matter  of  exercises  and  massage,  always  err  on  the  side 
of  light  and  delicate  treatment. 

There  are  many  movements  besides  these  that  have  been  enu- 
merated. In  my  first  article  I  described  38,  but  physicians  now 
usually  limit  themselves  to  a  much  smaller  number.  To  the  present 
list  of  15  double  ov  single  movements  I  sometimes  a.dd  Hcxion  of 
the  wrist  and  a)ikU\  making  a  total  of  17  movements.  But  I  now 
omit  all  exercises  in  which  the  hands  arc  raised  above  the  head, 
because  the  increased  resistance  thus  opposed  to  the  column  of  blood 
throws  more  work  on  the  heart. 

A  word  about  massage,  percussion,  and  vibration:  They  are  not 
onlv  useful  in  the  treatment  of  chronic  heart  diseases,  but  should 
form  a  part  of  any  system  ;  though  they  are  less  valuable  than  the 
exercises  and  baths.  They  are  especially  useful  in  lithaemic  and 
neurotic  patients. 

Abdominal  massage,  however,  is  prohibited,  because  in  dilated 
hearts,  for  which  this  treatment  is  mainly  applied,  the  liver,  spleen, 
and  other  chvlopoetic  viscera  are  apt  to  be  both  swollen  and  tender, 
and  therefore  liable  to  injury.  Besides,  as  shown  by  physiological 
experiments,  abdominal  massage  tends  to  inhibit  the  heart's  action. 
Massage  or  percussion  or  vibration  is  given  in  the  intervals  between 
the  voluntary  or  resistance  exercises,  largely  because  it  puts  a  bar 
upon  undue  muscular  efforts  on  the  part  of  the  patient  or  operator.^ 

THE    ARTIFICIAL    BATH. 

The  course  of  treatment,  which  usually  last  from  four  to  six 
weeks,  is  best  preceded  by  a  short  period  of  rest — from  two  to  three 
days  at  least,  during  which  the  patient's  various  functions  are  in- 
vestigated. At  first  the  baths  should  be  moderately  warm  and  saline ; 
later  cooler  and  more  saHne ;  still  later,  mildly  effervescent ;  finally 
chloride  of  calcium  is  added,  and  the  salines  and  carbonic  acid  gas 
increased,  while  the  temperature  is  decreased. 

The  duration  of  an  immersion  should  be  from  four  to  fourteen 


'  That  these  exercises  improve  the  rhythm  and  force  of  the  heart  and 
diminish  its  frequency  I  have  demonstrated,  latterly  in  the  Manhattan  State 
Hospital  West  at  clinics  held  there. 


X 


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in 


O 
I 

CO 


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'in.  39.— 'I'nmk  lleximi  lalerally.     Operator  iiidicalfd 
by  an  X. 


Nauheim  Methods  with  American  Adaptations  239 

minutes,  but  no  longer.  The  temperature  should  not  exceed  98°  F., 
nor  fall  very  far  below  it.  I  rarely  let  the  temperature  fall  below 
90°  F.  Sometimes  1  do  not  decrease  it  more  than  one  degree  during 
the  entire  course.  At  first  the  baths  are  given  with  an  intermission 
every  third  day,  later  every  fourth  day,  still  later,  every  fifth  day. 
On  the  day  of  intermission  the  physical  condition  of  the  patient 
should  be  thoroughly  looked  into.  The  efifect  of  carbonic  acid  gas 
on  the  skin  is  that  of  an  irritant  (Rose)  ;  with  the  salines  stimulating 
the  vasodilators  (Baruch). 

An  artificial  Nauheim  bath  can  be  improvised  in  many  different 
ways.  Any  one  who  can  get  sea  salt,  rock  salt,  or  ordinary  bathing 
salt,  calcium  chloride,  sodium  bicarbonate,  and  muriatic  acid,  and 
has  at  his  disposal  a  wooden,  porcelain,  or  enamelled  tub,  can  so 
imitate  the  original  Nauheim  method  as,  I  believe,  to  retain  its 
essential  therapeutic  qualities.  But  in  practice  it  has  been  found 
better  to  use  an  acid  sodium  sulphate  in  place  of  hydrochloric  acid, 
and  this  has  been  done  by  the  manufacture  of  solid  discs  of  the  acid 
sulphate,  which  may  thus  be  readily  handled  without  harm  to  one's 
person  or  clothes.  The  manufacturers  supply  the  carbonating  in- 
gredients in  a  wooden  box  about  8x6x4  inches  containing  in  dry 
compact  form  eight  discs  of  the  acid  sodium  sulphate  wrapped  in 
heavy  lead  foil,  and  four  packages  of  sodium  bicarbonate.^ 

In  preparing  the  baths,  break  the  discs  with  a  hammer,  put  them 
on  a  plate,  and  powder  them  over  with  the  bicarbonate.  In  about 
one  minute  after  the  ingredients  are  put  in  the  bath,  the  gas  will  be 
liberated. 

Both  the  bicarbonate  and  the  acid  sulphate  are  almost 
chemically  pure.  All  the  water  of  crystallization  has  been  elimi- 
nated from  the  discs,  which  contain  about  forty-two  per  cent,  of 
free  acid.  They  are  hard  and  do  not  deliquesce  at  any  tempera- 
ture, which  is  important.  They  keep  for  an  indefinite  time,  but. 
being  hard,  dissolve  slowly.  By  this  method  the  evolution  of  car- 
bonic acid  gas  is  continuous  until  the  tablets  are  dissolved,  and  as 
much  of  the  gas  is  given  off,  as  there  is  in  an  ordinary  carbonated 
bath  at  Nauheim. 

For  bathing  salt  I  often  prefer  to  begin  with  an  ordinary 
American  sea  salt,  as  by  so  doing,  I  get  the  benefit  of  the  iodides 
and  bromides  it  contains,  but  if  this  is  not  important,  I  use  a  good 
quality  of  dairy  salt,  such  as  the  Genesee.    At  the  end  of  the  first 


^Manufactured  by  the  Cassebeer  Pharmacal  Company,  loS  Fulton  Street^ 
New  York  City. 


240  Nauheim  Methods  with  American  Adaptations 

week,  1  carbonate  the  baths.  Then  when  a  large  amount  of  salt 
is  to  be  used,  1  substitute  ordinary  bathing  salt  for  the  sea  salt,  in- 
creasing at  the  same  time  the  amount  of  carbonic  acid  gas.  When 
the  gas  exists  in  a  fair  percentage  in  the  bath,  its  presence  is  shown 
by  minute  bubbles  attaching  themselves  to  the  body  of  the  bather.  At 
the  middle  of  the  course  1  fortify  my  ordinary  bathing  salt  with  the 
imported  Xauheim  Mutterlauge  (the  so-called  concentrated  brine 
salts).  By  so  doing  I  get  the  requisite  quantity  of  the  calcium  chlo- 
ride for  the  stronger  bath.  These  imported  Nauheim  concentrated 
salts  (Mutterlauge  salts),  contain  about  seventy-five  per  cent,  of 
calcium  chloride.  If  for  any  reason  it  is  desirable  to  have  a  bath  in 
which  all  the  ingredients  are  thoroughly  dissolved,  pure  calcium 
chloride  is  preferable  to  the  concentrated  brine  salts. 

An  ordinary  Nauhenn  bath  contains  from  two  to  three  and  one- 
half  per  cent,  of  salt,  of  which  eighty-two  per  cent,  is  sodium  chlo- 
ride and  ten  per  cent,  calcium  chloride. 

As  therefore  the  imported  concentrated  salts  are  rich  in  calcium 
chloride,  by  using  the  proper  proportion  of  them,  we  can  get  at  the 
same  time  the  requisite  quantity  of  calcium. 

My  scheme  for  the  ordinary  Six  Weeks'  Course  is  as  follows : 

First  Week.  (No.  i  Bath). — One-half  per  cent,  plain  warm 
salt  bath.  (Two  pounds  of  bathing  salt  to  50  gallons  of  warm 
water.)  Temperature,  98°  F.  Duration  four  minutes.  Intermis- 
sion on  the  third  and  sixth  days  of  this  week. 

Second  Week  (No.  2  Bath). — Three-quarters  per  cent,  warm 
salt  bath.  (Three  pounds  of  bathing  salt  to  50  gallons.)  One- 
quarter  per  cent,  carbonic  acid  gas  (two  discs  to  one  package). 
Temperature,  97°  F.  Duration,  six  minutes.  Intermission  on  the 
fourth  day  of  this  week. 

Third  Week  (No.  3  Bath). — One  per  cent,  warm  salt  bath 
(Four  pounds  of  bathing  salt  to  50  gallons.)  Temperature,  96°  F. 
Carbonated  acid  gas  one-half  per  cent,  (four  discs  to  two  packages). 
Duration,  eight  minutes.     Intermission  on  the  fourth  day. 

Fourth  Week  (No.  4  Bath). — One  and  a  quarter  per  cent,  salt 
bath.  Five  pounds  of  bathing  salt  to  50  gallons.)  Nauheim  con- 
centrated brine  salts,  8  ounces,  i.  e.,  a  half  pint  of  the  liquid  salts,  or 
Mutterlauge  ;  or  6  oz.  chloride  of  calcium.  Carbonic  acid  gas,  three- 
quarters  per  cent.  (Six  discs  to  three  packages.)  Temperature, 
95°  F.     Duration,  ten  minutes.     Intermission  on  the  fourth  day. 

Fifth  Week  (No.  5  Bath). — One  and  a  half  per  cent,  salt 
bath.     (Seven  pounds  of  bathing  salt  to  50  gallons.)     Concentrated 


Nauheim  Methods  with  American  Adaptations  241 

brine  (Mutterlange  salts),  three-quarters  of  a  pint  (12  ounces),  or 
9  ounces  chloride  of  calcium.  Carbonic  acid  gas,  three-quarters  per 
cent.  (Six  discs  to  three  packages.)  Temperature,  94°  F.  Dura- 
tion, 12  minutes.    Intermission  on  the  fifth  day. 

Sixth  Week  (No.  6  Bath). — Two  per  cent,  salt  bath.  (Ten 
pounds  of  bathing  salt  to  50  gallons.)  Concentrated  wet  brine  salts 
(Mutterlauge),  16  ounces,  i.  e.,  one  pint;  or  12  ounces  of  the  dry 
chloride  of  calcium.  Carbonic  acid  gas,  one  per  cent.  (Eight  discs 
to  four  packages.)  Temperature,  93°  F.  Duration,  14  minutes. 
Intermission  on  the  fifth  day. 

It  will  be  noticed  that  the  amount  of  carbonic  acid  gas  in  the 
bath  varies  from  one-quarter  to  one  per  cent. 

The  number  of  baths  in  a  full  course  is  35,  but  sometimes  a  less 
number  is  sufficient.  Twenty- four  is  a  good  average  number. 
With  robust  people  it  may  be  well  to  commence  at  once  with  the 
carbonated  brine  bath.  Sometimes,  especially  with  delicate  persons, 
the  Number  4  bath  will  be  as  strong  as  is  desirable. 

The  method  of  preparing  the  bath  is  as  follows :  Fill  the  bath- 
tub— preferably  of  porcelain  or  enamelled  iron — with  50  gallons  of 
water  at  about  105°  F. ;  then  add  the  ingredients  as  follows:  first 
add  the  required  quantity  of  bath  salt,  then  place  the  discs  of  the 
acid  sulphate  (broken  or  pulverized),  intermixed  with  the  sodium 
bicarbonate,  on  a  couple  of  saucers  or  on  a  single  plate  on  the  bottom 
of  the  tub.  An  evolution  of  gas  takes  place  in  a  minute  and  lasts 
20  or  more  minutes.  The  patient  should  enter  the  bath  when  it  has 
reached  98°  F.  or  lower,  according  to  the  directions,  and  remain 
in  it  the  prescribed  length  of  time.  As  soon  as  the  gas  is  evolved 
it  will  be  seen  attaching  itself  to  the  trunk  and  limbs  in  the  form  of 
minute  bubbles.  ° 

The  advantages  of  the  artificial  bath  may  be  briefly  summarized 
as  follows: 

It  contains  the  chief  natural  constituents  of  the  Nauheim 
waters,  and,  by  the  scheme  that  has  been  given,  is  applicable  in  most 
chronic  heart  diseases.  The  carbonic  acid  gas  is  held  in  better  solu- 
tion, by  the  artificial  bath,  than  by  the  natural  waters  of  Nauheim. 
The  artificial  bath  is  cleaner  than  the  natural,  which  contains  sub- 
stances of  no  obvious  utility.  The  artificial  bath  is  taken  at  home 
rather  than  in  a  public  resort  and  just  before  retiring,  so  that  there 
is  little  or  no  danger  of  catching  cold.  An  artificial  bath  costs  less 
in  this  country  than  in  Germany,  and  the  total  cost  of  the  treatment 
brings  it  within  the  reach  of  a  moderate  purse.    There  is  no  danger 


242  Nauheim  Methods  with  American  Adaptations 

from  free  carbonic  acid  gas,  as  it  is  held  in  closer  combination  than 
in  the  Nauheim  waters.  These  baths  can  be  given  at  any  time  of 
the  year.     The  discomforts  of  a  foreign  trip  are  avoided. 

On  the  other  hand,  there  are  certain  advantages  in  the  Nauheim 
natural  baths.  .  Whatever  of  virtue  there  is  in  the  natural  water  is 
retained.  The  jiatient  has  the  choice  of  numerous  physicians  of 
repute  in  the  treatment  of  chronic  heart  disease.  The  patient,  being 
away  from  home,  is  for  the  time  entirely  freed  from  many  of  the 
annoyances  of  business,  or  the  cares  of  private  life,  in  the  compara- 
tive seclusion  of  a  small  watering  place, — matters  of  value  in  the 
treatment.  He  may  lind  the  Nauheim  course  an  agreeable  feature 
of  a  summer  jaunt  abroad. 

Whether  it  is  better  to  take  a  course  at  home  or  abroad  is  for 
each  individual  to  decide  after  comparing  the  advantages  of  one 
with  the  other,  as  seen  from  his  special  point  of  view. 

So  far  as  the  actual  advantages  of  the  treatment  are  concerned, 
it  is  certainly  quite  as  well  given  in  this  country  as  in  Europe,  and 
with  more  comfort  to  the  patient.  In  fact,  one  disadvantage,  and  a 
serious  one,  of  the  European  baths,  is  that  they  are  not  given  in 
the  late  autumn,  winter,  or  early  spring ;  only  in  the  late  spring, 
summer,  and  early  fall. 

The  above  method  of  treatment  is  at  present  the  best  for  general 
use,  and  can  be  practiced  in  the  home. 

There  is,  however,  another  method  of  preparing  the  l^ath,  known 
as  the  Erlinger  system,  which  is  in  use  by  the  Harveian  Society  of 
New  York  City.^  Liquid  carbonic  acid  gas  from  a  drum  is  allowed 
to  pass  into  a  metal  chamber  containing  the  brine  solution.     Pad- 

"At  135  West  45th  Street,  New  York  City, 
dies  rotated  by  machinery  mix  the  gas  so  intimately  with  the  water 

that  it  is  retained  for  a  long  time  in  the  water.  The  temperature  of 
the  bath  is  regulated  by  the  addition  of  the  required  amount  of  hot 
water,  and  the  strength  of  the  bath  is  made  to  conform  to  the  physi- 
cians prescription.  In  place  of  the  concentrated  brine  salts,  chloride 
of  calcium  is  used,  in  the  requisite  quantities. 


Chapter  XXI. 

PROGNOSIS  IN  HEART  DISEASE. 

The  forecast  in  heart  diseases  involves  many  considerations,  and 
is  therefore  beset  with  uncertainties.  Age,  sex,  station  in  Hfe,  habits 
and  occupation,  the  variety  of  the  disease,  its  benign,  mahgnant, 
functional  or  organic  character,  its  location,  extent  and  duration, 
its  complications  and  accidents,  the  constitutional  diseases  with 
which  it  is  associated,  the  presence  or  absence  of  compensation,  and 
management,  intelligent  or  otherwise,  are  governing  factors  in  the 
expectation  of  life. 

In  infants  under  one  year  the  outlook  is  particularly  unfavorable. 
During  childhood  it  is  worse  than  in  adult  life.  Children  with 
serious  valvular  diseases  before  eight,  seldom  reach  adult  life.  As 
they  approach  puberty,  heart  weakness  is  apt  to  set  in.  Holt  found 
that  in  225  cases  of  congenital  heart  disease,  60  per  cent,  were  fatal 
before  the  end  of  the  fifth  year,  and  one-half  during  the  first  two 
months  ;  16  per  cent,  of  the  cases,  however,  lived  over  16  years,  and 
8  per  cent,  over  30  years.  Serious  valvular  lesions  in  children  pro- 
gress more  quickly  than  in  adults.  Owing  to  their  rapid  growth, 
and  the  demands  made  on  their  strength,  cardiac  dilatation  occurs 
early.  Acute  diseases  still  further  increase  the  danger  to  life.  (Dis. 
of  Infancy,  New  York,  1902.) 

But  the  danger  is  not  immediate.  In  fact,  both  acute  and  chronic 
endocarditis  in  children  are  rarely  of  themselves  fatal,  death  being 
due  to  associated  conditions,  such  as  pneumonia  or  pleurisy. 

We  see  then  how  it  is  that  the  first  years  of  life  are  especially 
dangerous  for  children  with  heart  disease.  However,  according  to 
Koplik  (Dis.  of  Infancy,  N.  Y.,  1902),  in  mild  forms  of  heart  disease 
in  children,  recovery  is  to  be  expected,  though  the  outlook  in  rheu- 
matic patients  is  especially  unfavorable,  for  they  are  apt  to  succumb 
within  a  few  hours  after  the  first  attack. 

Women  have  a  better  expectation  of  life  than  men,  because  their 
lives  are,  on  the  whole,  less  strenuous  and  more  orderly,  though 
during  pregnancy  and  parturition  they  run  great  risks ;  in  the  one 
case  from  the  upward  pressure  of  the  abdominal  organs,  and  in  the 
other  from  the  severe  efforts  of  expulsion,  with  resulting  cardiac 
strain,  due  to  the  suddenly  altered  circulation.     Heart  failure  may 


244  Prognosis  in  Heart  Disease 

cause  death  under  any  of  these  circumstances.  In  pregnant  women, 
however,  the  greatest  distension  and  pressure  is  forwards  rather 
than  upwards.  Though  instrumental  interference  under  anaesthetics 
is  frequently  resorted  to,  the  treatment  of  heart  complications  is 
much  better  understood  than  formerly.  According  to  Edgar,  if  the 
disease  is  valvular,  and  there  is  compensation,  the  danger  to  life 
is  small,  and  need  not  be  taken  seriously,  though  the  induction  of 
artificial  labor  may  sometimes  be  necessary.  Mitral  stenosis  is  most 
dreaded  by  obstetricians.  If  death  does  not  result,  there  mav  be 
placental  apoplexy  or  abortion.  Nitrous  oxide  or  ether  "^re  the 
preferable  anaesthetics.  During  pregnancy  and  after  child-birth, 
strychnine  is  sometimes  given,  digitalis  rarely.  Uncompensated  en- 
docarditis is  unfavorable  for  mother  and  child. 

For  men  whose  occupations  call  for  continuous  or  violent  physi- 
cal strain,  exposure  to  inclement  weather,  especially  if  they  take 
stimulants  in  the  place  of  proper  food,  the  prognosis  is,  as  a  rule, 
unfavorable.  Yet  among  men  or  women  who  live  regular  lives,  free 
from  its  ordinary  vicissitudes,  a  fright  or  mental  strain,  overeating, 
arrested  digestion,  the  immoderate  use  of  tobacco,  or,  indeed,  any 
sudden  tax  on  the  system,  may  cause  a  fatal  result.  In  very  old 
people  a  rather  common  cause  of  sudden  death  from  heart  disease  is 
the  eating  of  indigestible  food,  or  more  food  than  can  be  digested. 

It  is  true  that  from  the  gradually  accumulating  facts  about  heart 
diseases,  we  are  getting  more  definite  views  as  to  the  expectation  of 
life,  and  from  the  increasing  care  with  which  post-mortem  examina- 
tions are  made  in  our  public  institutions,  we  may  expect  still  greater 
definiteness  in  the  future.  But  still  we  are  very  deficient  in  data 
for  making  accurate  estimates,  so  that  our  forecasts  are  necessarily 
vague.  Still  a  certain  number  of  facts  governing  the  expectation 
of  life  are  known. 

It  is  generally  admitted  that  functional  diseases  of  the  heart  do 
not  much  afifect  longevity,  though  they  certainly  make  the  organ 
more  susceptible  to  disease,  while  the  malignant  forms,  whether  due 
to  new  growths  or  mfective  endocarditis  or  carditis  are  pretty  gener- 
ally fatal.  Certainly  two-thirds  of  the  recorded  cases  of  malignant 
endocarditis  have  proved  fatal. 

On  the  whole,  perhaps,  myocardial  diseases  are  less  dangerous 
to  life  than  the  endocardial.  Certainly  myocardial  degenerations 
due  to  the  continued  fevers,  like  typhoid  and  diphtheria,  will,  in  the 
great  majority  of  cases,  disappear  after  convalescence,  and,  reason- 


Prognosis  in  Heart  Disease  245 

ing  by  analogy,  flegcnerative  changes  due  to  other  causes  should 
yield  under  appropriate  treatment ;  it  is  certain  that  the  fat  heart 
of  corpulence  will  greatly  improve  under  the  intelligent  application 
of  reduction  methods.  At  the  same  time  sudden  death  occurs  more 
frequently  in  myocardial  disease  than  is  generally  supposed.  Per- 
sons with  very  fatty  hearts  will  sometimes  die  as  if  from  an  apoplectic 
stroke.  The  cause  may  be  acute  dilatation,  or  embolism  due  to 
thrombi  detached  from  the  chambers  of  the  heart ;  in  some  cases 
rupture ;  or  they  may  die  more  gradually  from  extrinsic  causes,  such 
as  pneumonia,  or  gastro-intestinal  distention  ;  more  generally,  how- 
ever, from  affections  of  internal  organs  (in  which  the  lungs,  kidneys, 
liver  play  the  most  important  roles),  and  which,  indeed,  are  the  ter- 
minal affections. 

In  myocardial  diseases  where  there  is  arteriosclerosis,  or  in  de- 
generation of  the  heart  walls,  where  there  is  a  persistently  feeble 
pulse,  especially  with  difference  in  the  radials,  the  danger  line  is 
always  near  at  hand.  Myocardial  syphilis  must  also  be  reckoned 
with  as  a  cause  of  death. 

Mitral  obstruction  is  more  serious  than  insufficiency.  Mitral 
obstruction,  if  severe,  means  that  the  mitral  disease  is  well  estab- 
lished. Moreover,  embolism  may  occur  as  often  as  in  20  per  cent, 
in  cases  of  mitral  obstruction,  in  my  experience.  In  Hayden's  15 
cases  death  was  at  an  average  age  of  29.26  years.  In  Broadbent's  53 
cases  of  mitral  stenosis  it  was  33  years  for  males  and  37.38  for 
females.  Samways  {Brit.  Med.  Jour.,  Feb.  5,  1898),  in  196  cases 
taken  from  the  records  of  Guy's  Hospital,  found  the  average  age 
at  death  for  males  was  38  1-3  years,  and  for  females  the  same.  In 
severe  stenosis  the  average  age  was  33.6  years,  in  the  milder,  43.6. 
In  42  fatal  cases  by  Fagge,  the  average  age  was  37.83.  (Hayden, 
Dis.  of  the  Heart,  Dublin,  1875.)  In  one-third  of  them,  however, 
there  was  complication  with  other  valves.  According  to  my  personal 
statistics,  in  one  series  of  19  cases  death  most  frequently  took  place 
between  2,7  and  38,  but  the  extremes  in  these  cases  varied  from  2t, 
to  70,  and  the  mean  age  was  found  to  be  39.2.  By  reference,  how- 
ever, to  page  60  of  this  manual,  the  average  age  at  death  in  Dyce 
Duckworth's  cases,  264  in  number  (not  all,  however,  supported  by 
post-mortem  evidence),  was  35.  In  a  first  series  of  100  collected 
cases,  I  found  the  average  age  35,  in  a  second  series  33.  Sansom 
found  it  32.7.     In  another  series  of  57  fatal  cases,  ranging  from  13 


246  Prognosis  in  Heart  Disease 

to  67,  26  or  45.6  per  cent,  fell  between  the  ages  of  30  and  40  inclusive. 
The  expectation  of  death  is  therefore  in  the  fourth  decade,  and  so  far 
as  we  know  at  present  at  about  the  age  of  34.  I  have,  however, 
under  observation  a  patient  of  jt,.  with  tyi)ical  signs  of  mitral 
stenosis,  including  the  purring  thrill. 

In  mitral  stenosis  sudden  death  is  as  rare,  comparatively,  as  it  is 
frequent  in  aortic  insufficiency.  In  five  of  my  cases  it  was  said  that 
the  disease  had  lasted  anywhere  from  three  to  thirty  years. 

Aortic  insufiticiency  is  certainly  one  of  the  most  dangerous  of 
valvular  diseases,  but  at  the  same  time  it  is  less  so  in  the  absence 
or  arteriosclerosis  or  angina,  or  where  there  is  little  displacement, 
and  the  contour  of  the  heart  is  not  much  altered.  WhetTier  it  is 
more  grave  than  aortic  stenosis  has  been  questioned.  In  50  of  my 
cases  the  averages  of  age  at  death  was  40  against  41.7  for  aortic 
stenosis,  but  the  stenosis  was,  for  the  most  part,  complicated  with 
other  valvular  affections. 

Pure  aortic  stenosis  has  a  more  favorable  outlook.  Compara- 
tively few  cases  have  been  recorded,  however.  In  8  of  which  I  have 
records,  the  average  age  at  death  was  56,  two  reaching  the  age  of 
70  and  one  90. 

In  Hayden's  26  aortic  cases,  50  per  cent,  were  combined  with  in- 
sufficiency. I  make  it  65  per  cent,  in  my  cases.  Fagge  says,  and  I 
think  with  truth,  that  in  combined  aortic  stenosis  and  insufficiency 
the  prognosis  is  governed  by  the  insufficiency.  Judging  from  my 
figures,  aortic  obstruction  in  complicated  cases  is  almost  as  serious 
as  incompetence,  but  much  less  so  in  uncomplicated  cases.  In  aortic 
obstruction,  however,  arteriosclerosis  must  always  be  regarded  as 
an  unfavorable  sign.  But  the  prognosis  depends  largely  on  the 
grade  of  obstruction.  If  little,  the  prognosis  is  not  bad,  compara- 
tively speaking.  Broadbent  found  the  average  age  at  death  40  years, 
while  his  oldest  case  was  53.  He  thinks  aortic  stenosis  less  serious 
than  aortic  insufficiency  or  mitral  stenosis,  in  which  I  agree  with 
him  on  the  whole.  However,  sudden  death  in  my  experience  is  as 
common  in  aortic  stenosis  as  in  incompetence.  In  both  I  found 
it  20  per  cent.  Hayden  made  it  18  per  cent,  in  all  forms  of  aortic 
disease. 

Mitral  insufficiency  is  compatible  with  a  long  life.  This  is  now  the 
accepted  opinion.  Indeed,  in  uncomplicated  mitral  insufficiency  the 
outlook  is  better  than  in  any  other  form  of  valvular  disease.  The 
relative  form  is  quite  common  after  physical  exercise,  in  recovery 


Prognosis  in  Heart  Disease  247 

from  fevers,  and  in  neurotic  disturbances.  Most  athletes  suffer 
from  it  at  some  time  or  otlier,  Imt  it  usually  disappears  when  the 
strain  is  past.  On  the  other  hand,  it  may  be  a  fixture  in  some,  as 
in  laboring  men,  if  there  is  continuous  and  hard  strain.  Still,  simple 
mitral  insufficiency  acquired  in  early  life  appears  to  yield  more  easily 
to  compensatory  hypertrophy  than  any  other  form  of  valve  diseases. 

In  the  organic  variety  it  is  apt  to  be  complicated  with  other  valvu- 
lar diseases.  My  figures  show  this  complication  in  86  per  cent,  of 
cases.  Moreover,  I  believe  that  mitral  stenosis  is  preceded  by  mitral 
insufficiency.  I  am  not  sure  that  it  ever  causes  death  of  itself.  In 
fact,  in  a  record  of  102  fatal  cases  of  heart  disease,  I  have  not  found 
a  single  instance  of  organic  uncomplicated  mitral  insufficiency  that 
caused  death. 

To  my  mind,  therefore,  the  comparatively  harmless  character  of 
uncomplicated  mitral  insufficiency  is  clearly  established.  The  great 
danger,  however,  is  that  in  practice  mitral  stenosis,  one  of  the  most 
dangerous  of  the  common  valve  lesions,  will  be  mistaken  for  mitral 
insufficiency,  the  least  dangerous.  This  error  has  often  been  made, 
as  my  hospital  records  show. 

In  congenital  pulmonary  insufficiency  the  prognosis  is  never 
good,  but  in  acquired  disease,  I  have  known  of  one  instance  in  which 
the  patient  reached  the  age  of  70. 

In  congenital  pulmonary  obstruction  (stenosis),  the  majority 
die  before  the  fourth  year,  and  of  tuberculosis,  but  the  age  of  40 
has  been  reached.  Acquired  obstruction  has  a  more  favorable  out- 
look. Owuig  to  the  position  of  the  valve  it  is  apt  to  be  compressed 
by  external  influences,  such  as  adhesions.  Of  my  four  cases  one 
lived  to  be  56,  and  in  15  of  my  collected  cases  42.8  was  the  average 
of  age  at  death.  One  patient  (Schwalbe's)  lived  to  84.  These 
cases,  however,  are  too  few  for  statistical  purposes.  Pulmonary 
obstruction  is  the  point  about  which  all  congenital  cardiac  anomalies 
center.  Independent  of  the  pulmonary  lesion,  thev  are  apt  to  be 
incompatible  with  a  long  life. 

Tricuspid  obstruction  is  for  the  most  part  an  acquired  disease. 
It  is  very  rarely  congenital,  and  when  so,  is  soon  fatal ;  it  is,  in 
fact,  the  most  dangerous  of  all  valvular  diseases.  Usually  it  occurs 
in  the  train  of  organic  valvular  diseases ;  and  is  the  latest  of  them. 
Patients  seldom  reach  40,  but  one  of  Leudet's  cases  lived  to  be  64. 
Exceptionally  old  age  may  be  reached.  In  one  case  that  I  have  re- 
ported, the  patient  lived  to  be  70.    Samways,  in  196  cases  of  valvular 


248  Prognosis  in  Heart  Disease 

diseases,  found  32  of  tricuspid  stenosis,  so  that  it  is  not  extremely 
rare.  The  prognosis  depends  largely  upon  the  condition  in  life.  It 
is  more  dangerous  in  women  than  in  men  ;  and  in  laboring  classes 
than  in  those  whose  circumstances  are  easy. 

In  tricusjMcl  insufficiency  the  prognosis  is  bad,  if  it  is  secondary 
to  lung  disease  or  some  other  valvular  affection.  It  is  apt  then  to  be 
a  terminal  affection.  It  may,  however,  be  a  temporary  affair,  and 
of  little  account.  Yet  if  it  persists,  the  significance  is  very  grave. 
The  order  of  gravity,  as  given  by  Wilks,  Peacock,  Bristowe,  Fagge, 
and  Pye-Smith,  is : 

1.  Aortic  regurgitation. 

2.  Mitral  regurgitation. 

3.  Mitral  stenosis. 

4.  Aortic  obstruction. 

And  as  given  by  Green  {Mcdica!  B.vcniiiiiafion  for  Life  Ins., 
1900),  it  is: 

1.  Aortic  regurgitation. 

2.  Mitral  stenosis. 

3.  Aortic  stenosis. 

4.  jNIitral  regurgitation. 
While  Walshe  made  the  order : 

1.  Tricuspid   regurgitation. 

2.  Mitral  regurgitation. 

3.  Mitral  stenosis. 

4.  Aortic  incompetence. 

5.  Pulmonary  obstruction. 

6.  Aortic  obstruction. 

On  the  other  hand,  15roadbent  and  Leyclen  have  it: 

1.  Aortic   incompetence. 

2.  Mitral  stenosis. 

3.  Aortic  stenosis. 

4.  Mitral  regurgitation. 

In  the  statements  and  figures  just  given,  it  is  apparent  that  if 
T/e  are  to  judge  of  the  gravity  of  the  disease  by  the  average  age  at 
death,  the  order  should  be  as  follows  in  the  four  conditions  named: 

1.  Mitral  obstruction   (stenosis). 

2.  Aortic  insufficiency. 

3.  Aortic  obstruction   (stenosis). 

4.  Mitral   insufficiency. 

This  order  of  gravity  often  obtains,  according  to  Broadbent,  in 


Prognosis  in  Heart  Disease  249 

childhood  and  early  adolescence.  My  statistics,  however,  are  drawn 
almost  entirely  irom  adult  cases,  and,  1  believe,  from  a  larger  series 
of  post-mortem  cases  than  have,  as  yet,  been  utilized  in  the  solution 
of  cardiac  problems. 

Certain  other  matters  bear  on  the  prognosis.  For  example,  it  is 
to  be  remembered  that  the  intensity  of  a  murmur  does  not  indicate 
the  gravity  or  extent  of  the  inflammatory  process.  Well  defined  mur- 
murs that  come  and  go  are  apt  to  belong  to  loose  vegetations  and 
are  therefore  alarming.  Musical  murmurs,  attended  with  fever, 
always  give  an  unfavorable  prognosis.  They  are  likely  to  be  caused 
by  rupture  or  ulceration  of  a  valve.  Loud  murmurs  suggest  a  large 
opening.  The  change  from  a  loud  to  a  soft  murmur,  however,  is 
apt  to  indicate  commencing  heart  failure.  Diastolic  murmurs  are 
the  most  dangerous.  The  Cheyne-Stokes  or  Adams-Stokes  signs  are 
significant  of  cerebral  implication,  and  though  they  may  disappear, 
in  rare  cases,  point  to  eventual  danger  from  cerebral  disease.  Re- 
curring attacks  of  inflammatory  rheumatism  make  the  outlook  un- 
favorable. In  any  form  of  endocarditis,  a  sharp  attack  of  pneu- 
monia, or  even  any  prolonged  illness  that  wastes  the  vital  forces, 
may  cause  heart  failure. 

In  the  main,  however,  in  valvular  disease,  the  prognosis  hangs 
on  eilicient  or  non-efiicient  compensation.  If  the  apex  beat  is  in 
about  the  normal  position,  the  rhythm  regular,  the  action  of  the 
heart  good,  and  there  is  no  considerable  increase  in  the  transverse 
dulness,  auscultatory  phenomena  are  of  subordinate  importance. 

In  fact,  so  long  as  compensation  is  maintained  in  these  cases 
there  is  no  immediate  danger  of  sudden  death,  unless  from  embolism, 
which,  however,  may  occur  at  any  time.  Still  the  embolus  mav  not 
reach  a  point  of  vital  importance.  It  may  lodge  in  the  liver  or  lungs, 
without  doing  much  harm ;  if  in  the  medulla  or  pons,  it  will  probably 
cause  immediate  death.  I  have  seen  a  case  where  a  clot  lodged  in 
the  pons  produced  this  result.  If,  however,  it  is  lodged  in  a  "silent 
center,"  it  may  do  no  harm.  Diseases  of  the  right  side  of  the  heart 
are  more  immediately  dangerous  because  they  produce  more  venous 
congestion,  which  leads  in  turn  to  a  greater  exudation  of  fluid  and 
its  attendant  consequences.  It  is  commonly  believed  that  the  dropsi- 
cal efifusions  seen  in  the  last  stages  of  cardiac  diseases  are  due  to 
congestion  of  the  kidneys.  This  seems  to  be  true  in  most  cases,  but 
the  liver  and  spleen  are  almost  as  often  involved.  Indeed,  the  hob- 
nail liver  is  quite  common  in  old  cases  of  heart  disease. 


250  Prognosis  in  Heart  Disease 

In  compensatory  hypertrophies  the  right  ventricle  fails,  as  a 
rule,  earlier  than  the  left.  Hypertrophy  compensates  for  a  variable 
periotl.  dependent  chieriy  on  the  extent  of  the  disease  in  the  valve  or 
valves  atTected.  It  was  at  one  time  computed  that  the  expectation  of 
life  in  ordinary  cases  is  from  two  to  four  years  after  compensation 
has  failed.  The  expectation  of  life  in  cardiac  diseases  has  been 
greatly  improved,  however,  by  a  closer  attention  to  diagnosis,  a 
more  discriminating  use  of  drugs,  and  a  recognition  of  the  success 
obtained  by  mechanical  methods.  Whether  or  not  the  claim  made 
by  the  advocates  of  the  Xauheim  system  that  it  adds  an  average  of 
ten  years  to  life,  is  true,  it  is  an  interesting  problem  and  one  worthy 
of  close  statistical  inquiry. 


Chapter  XXIT. 

TRUE   ANEURISMS    OF    THE    LARGER    VESSELS    AND 
THEIR  BRANCHES. 

Aneurisms  more  often  affect  the  thoracic  aorta  than  any  other 
artery  of  the  body.  Sometmies  they  are  sacculated,  that  is,  formed 
by  a  local  bulging  of  the  vessel's  walls.  But  general  or  non-saccular 
dilatations  are  just  as  truly  aneurisms,  for  the  Greek  word  "aneu- 
rysma"  means  a  dilatation,  and  in  the  ascending  portions  of  the 
arch  these  dilatations  are  frequent  enough,  under  the  generic  name 
of  fusiform  aneurisms,  because  the  dilated  portion  of  the  aorta  is 
spindle-shaped.  Other  varieties  are  much  rarer,  such,  for  example, 
as  the  arterio-venous,  where  there  is  a  communication  between  an 
artery  and  vein,  such  as  results  from  a  penetrating  wound.  There 
are  still  other  kinds,  but  the  present  chapter  is  mainly  concerned  with 
sacculated  aneurisms. 

In  passing,  it  may  be  said  of  fusiform  aneurisms  that  they  stand 
apart  from  the  sacculated.  Confined  mostly  to  the  ascending  part 
of  the  arch,  they  are  seldom  large  enough  to  produce  any  pressure 
symptoms,  and  rarely  have  the  thrill  or  double  murmur  of  the  sac- 
culated variety.  In  fact,  they  have  a  life  history  of  their  own,  which 
places  them  in  a  special  category.    They  are  discussed  elsewhere. 

Sacculated,  otherwise  known  as  true  thoracic  or  abdominal 
aneurisms,  may  reach  the  size  of  a  child's  head,  but  seldom  come  to 
our  notice  under  the  size  of  a  pullet's  egg.  Though  occasionally  due 
to  mechanical  injury,  they  are  generally  the  result  of  arterial  disease 
or  weakness. 

Syphilis,  gout,  alcoholism,  and  severe  manual  work,  are  the 
reputed  causal  factors,  and  the  imputation  is  probably  just,  be- 
cause each  of  these  agencies  will  cause  abnormal  thickness  of  the 
arteries.  I  am  inclined  to  think  that  syphilis  is  the  most  potent 
cause,  though  it  is  not  easy  to  prove  it  from  statistics.  Alalmsten 
made  it  the  cause  in  80  per  cent.,  5  per  cent,  being  due  to  gout  and 
5  per  cent,  to  alcoholism.  My  limited  experience  also  indicates  the 
predominating  influence  of  syphilis. 

Males  are  certainly  more  liable  to  aneurism  than  females.  In 
fact,  the  proportions  have  been  put  at  8  to  i.  In  my  11  cases  here 
recorded,  but  i  was  a  female.     Naturally  it  occurs  most  frequently 


2^2  True  Aneurisms 

in  the  middle  decades  of  life,  when  degenerative  changes  are  most 
common,  such  as  the  third,  fourth  and  fifth,  especially  the  latter. 

Aneurisms  may  persist  for  years,  or  at  any  time  cause  death 
from  internal  hemorrhage,  or  in  some  indirect  manner,  as  by  strang- 
ulation, pressure  on  the  trachea,  pneumonia,  heart  failure,  etc.,  as 
the  cases  given  later  show.  Spontaneous  cure  is  seen  in  small 
aneurisms,  rarely  in  larger  ones.  In  the  development  of  aneurisms, 
much  depends  on  the  environment  of  the  individual.  The  growth 
is  most  rapid  in  those  who  lead  a  life  of  activity,  excitement,  or 
indifference  to  the  laws  of  health.  When  a  cure  takes  place,  it  is 
because  the  sac  has  been  filled  with  fibrin,  and  its  walls  impregnated 
with  the  salts  of  lime,  both  shrinking  so  as  to  change  the  tumor  into 
a  solid  ball ;  or  it  may  be,  that  some  peripheral  inflammation  has 
enveloped  the  sac  and  contracted  it.  as  in  Case  No.  LXXXII. 

In  the  differential  diagnosis  of  these  aneurisms  there  are  no 
really  pathognomonic  signs.  In  fact,  reliance  must  be  placed  both 
on  ph>sical  and  subjective  phenomena,  and  yet  the  one  or  the  other, 
or  both,  may  be  absent.  This  statement  may  help  to  explain  why  my 
experience  tells  me  that  in  thoracic  and  abdominal  aneurisms  the 
diagnosis  is  made  only  in  a  little  more  than  25  per  cent,  of  the  cases. 

In  the  diagnosis  of  a  thoracic  or  abdominal  aneurism  we  first 
think  of  a  pulsating  tumor.  If  the  orifice  leading  into  the  sac  were 
large,  the  walls  thin,  and  the  contents  only  liquid  blood,  we  should 
more  often  feel  the  abnormal  pulsation.  The  opening,  however, 
mav  be  small  and  the  contents  largely  composed  of  clotted  or 
laminated  blood.  Perhaps  the  sac  is  so  deep  down  in  the  tissues  as 
not  be  reached  by  any  kind  of  palpation.  In  such  instances, 
we  recognize  neither  pulsation  nor  heaving  impulse.  If,  however, 
the  sac,  in  a  thoracic  aneurism,  for  example,  reaches  the  level  of  the 
intercostal  cartilages,  the  episternal  notch  or  the  ribs,  pulsation  may 
be  felt.  When  the  sac  is  large,  it  may  be  mapped  out  by  percussion. 
or  bv  the  X-ray.  I  successfully  accomplished  this  by  the  latter 
method  in  a  thoracic  aneurism  brought  to  my  notice  by  Dr.  Katzen- 
bach  of  this  city  as  early  as  1897.  In  this  instance  the  aneurism  was 
probablv  filled  with  more  or  less  laminated  fibrin,  which  gave  the 
shadow. 

Aneurisms  are  most  frequently  found  in  the  arch  of  the  aorta,  and 
I  think  it  best  to  consider  this  class  together,  whether  they  pro- 
ceed from  the  ascending,  transverse  or  descending  portion,  because 
it  is  practically  impossible  infra  vitam  to  distinguish  just  where 
they  originated.    The  symptoms,  being  due  to  pressure,  can  not  be 


True  Aneurisms  253 

referred  to  the  vessel,  but  to  the  sac,  and  the  latter  may  assume  any 
position  in  the  thorax,  that  is,  it  may  project  to  the  right  or  left, 
upwards  or  downwards,  forwards  or  backwards.  Still  it  is  true, 
taking  the  sum  total  of  signs  in  a  number  of  these  aneurisms,  in  the 
several  divisions  of  the  arch,  there  will  be  certain  symptoms  more 
apt  to  be  specially  connected  with  each  division,  as  will  be  shown. 

In  general,  if  the  sac  compress  the  superior  vena  cava,  there 
will  be  enlargement  of  the  veins  of  the  head  and  neck ;  if  the  inferior 
vena  cava,  oedema  of  the  lower  extremities.  If  the  sac  press  on  the 
trachea,  it  may  produce  cough  and  dyspnoea,  and  even  suffocation, 
as  in  Case  No.  LXXXV ;  if  on  the  right  pulmonary  artery,  embolism 
may  follow.  If  the  recurrent  laryngeal  is  pressed  on,  there  may  be 
hoarseness  or  difficulty  in  phonation.  Compression  of  the  oesoph- 
agus will  cause  dysphagia ;  pressure  on  the  vertebra,  erosion  of 
the  spine.  Rupture  may  take  place  into  the  oesophagus,  peritoneum, 
pericardium,  superior  vena  cava,  trachea  or  bronchi,  etc.  Very  oc- 
casionally an  aneurism  bursts  externally.  If  there  is  a  large  thoracic 
tumor,  there  will  generally  be  displacement  of  the  heart.  A  small 
aneurism  may  give  rise  to  a  diastolic  or  systolic  murmur,  or  both, 
and  yet,  at  times,  it  may  be  impossible  to  distinguish  these  murmurs 
from  the  valvular.  However,  the  murmurs  are  usually  louder  than 
the  latter.  The  sternum  may,  in  advanced  cases,  be  eroded  and 
pushed  forward,  making  a  tender  and  painful  tumor.  The  hand 
pressed  on  it  may  detect  a  thrill,  or  perhaps  a  pulsation.  Separation 
of  the  fingers  placed  over  the  pulsating  area  may  show  its  expansile 
character.  Usually  the  pulsation  is  to  the  right  of  the  sternum.  If 
the  sac  has  solid  or  semi-solid  contents,  there  will,  of  course,  be  no 
expansion.  The  sac  may  also  press  on  the  thoracic  duct.  The  in- 
nominate or  left  carotid,  or  sub-clavian,  ma}^  be  involved  in  the 
tumor.  There  may  be  pain  from  pressure  on  the  cardiac  plexus, 
on  the  nerves  of  the  pleura,  pericardium  or  skin.  Pressure  on  the 
branches  of  the  sympathetic  causes  inequality  of  the  pupils,  as  seen 
in  Case  No.  LXXXIII,  pressure  on  the  pneumo-gastric,  spasm  of 
the  oesophagus  and  vomiting.  If  there  is  pressure  on  a  bronchus 
there  may  be  catarrh  of  the  mucous  membranes,  with  retention 
of  the  secretions  and  broncho-pneumonia  that  will  cause  death. 
Pressure  on  the  innominate  or  sub-clavian  artery  \vill  necessarily 
produce  some  effect  on  the  pulse  of  the  affected  side,  and  this  is  a 
valuable  sign.  Pressure  on  the  innominate  vein  may  produce  venous 
congestion  of  the  side  of  the  head.  There  may  be  compression,  ob- 
struction and  obliteration  of  the  pulmonary  artery.     An  important 


254  True  Aneurisms 

sign  of  aneurism  in  this  kication  is  thought  by  some  to  be  "tracheal 
fugging.  This  is  produced  in  the  following  way:  let  the  patient 
stand  and  raise  his  chin  to  the  farthest  extent,  then  seize  the  cricoid 
cartilage  between  finger  and  thumb  and  raise  it  gently  ;  if  there  is  an 
aneurism  of  the  arch,  the  pulsation  of  the  aorta  may  possibly  be 
transmitted  through  the  trachea  to  the  fingers.^  This  should  be 
an  early  sign,  but  it  does  not  appear  to  be  very  reliable.  Grimshaw 
found  it  in  i6  per  cent,  of  persons  who  had  no  aneurism.  There 
may  be  or  may  not  be  cardiac  hypertrophy.  A  laryngeal  examina- 
tion is  important,  as  it  may  reveal  paresis  of  a  vocal  chord.  If  there 
is  any  weakness  of  the  chord,  it  will  be  indicated  in  uttering  the 
exclamation  "Ah."  Paroxysmal  attacks  of  dyspnoea  are  attributable 
to  paresis  of  the  pneumo-gastric.  Bronchorrhoea  and  suppuration 
of  the  lungs  ma}-  also  be  due  to  paresis  of  this  nerve.  These  signs 
may  occur  when  there  is  even  a  small  aneurism  of  the  aorta,  and 
such  aneurisms  are  often  fatal.  The  pain  may  be  ver)-  intense.  Small 
aneurisms  of  the  transverse  portion,  where  the  tumor  is  no  larger 
than  a  hen's  egg.  are  common,  and  the  diagnosis  may  sometimes  be 
made  by  an  experienced  clinician,  from  a  due  consideration  of  all  the 
signs  physical  and  rational,  as  Case  LXXXIII.  shows. 

When  the  tumor  is  the  size  of  one's  fist,  percussion  should  indi- 
cate its  locality,  but  I  have  known  a  thoracic  aneurism  ten  inches 
in  diameter  to  escape  the  notice  of  a  careful  practitioner.  A  loud 
murmur  indicates  a  small  opening,  and  vice  versa.  In  one  of  my 
cases  the  sound  resembled  the  strokes  of  a  locomotive  piston.  In 
such  cases  we  ma}'  distinguish  these  murmurs  from  those  of  the 
heart.  According  to  Douglas  Powell,  however,  in  about  one-half 
the  cases  there  is  no  murmur  in  thoracic  aneurism.  In  seven  of  my 
cases  murmurs  occurred  in  but  two.  The  bruit  may  perhaps  be 
best  heard  by  opening  the  mouth  and  introducing  the  stethoscope 
between  the  teeth.  The  heart  is  pretty  sure  to  be  hypertrophied  and 
sometimes  displaced,  while  valvular  lesions  will  often  be  a  complica- 
tion and  the  diagnosis  difficult. 

The  following  cases  are  taken  from  my  records  during  the  period 
when  I  was  pathologist  to  the  St.  Luke's  and  Presbyterian  Hospitals 
of  this  city: 

Case  LXXXII.  Aortic  Disease;  Aneurism  of  the  Ascending 
Portion  of  the  Arch;  Syphilis;  Death  from  Heart  Failure.  Ten- 
dency to  Spontaneous  Cure. — M.,  38,  a  painter,  was  admitted  to 
hospital  January  10,  1883,  with  a  history  of  syphilis,  and  complain- 

'  Oliver. 


True  Aneurisms  255 

ing  of  soreness  over  the  Unver  ])art  of  his  chest.  On  pliysical  ex- 
amination an  aortic  regurgitant  murmur  was  recognized.  The 
patient  died  after  a  short  stay  in  hospital,  during  a  sudden  attack 
of  dyspncea  lasting  only  25  minutes. 

At  the  post-mortem  examination  there  was  found  to  be  both 
aortic  regurgitation  and  stenosis,  and  the  cause  of  death  was  at- 
tributed to  heart  failure ;  but  there  was  also  a  sacculated  aneurism 
about  the  size  of  a  hen's  egg  above  the  aortic  valves.  The  sac  lay 
partly  under  the  root  of  the  right  lung,  where  it  had  caused  much 
irritation,  leading  to  deposits  of  fibrin,  which  had  prevented  rupture. 
Gummy  tumors  were  found  in  the  liver.  This  case  is  a  good  illus- 
tration of  the  fact  that  a  thoracic  aneurism  in  this  locality  up  to  the 
size  of  a  hen's  egg  is  seldom  diagnosticated,  even  by  the  best  clini- 
cians. 

In  aneurism  of  the  transverse  portion  of  the  arch,  there  is  a  wide 
range  of  pressure  symptoms,  but,  as  a  rule,  they  are  not  so  marked 
as  in  aneurism  of  the  ascending  portion. 

Case  LXXXIII.  Broncho-Pnciunonia;  Chronic  Diffuse  Ne- 
phritis; Aneurism  of  the  Transverse  Part  of  the  Arch;  Death  Due 
to  Pneumonia  and  Chronic  Diffuse  Nephritis. — R.,  38,  painter,  was 
admitted  to  hospital  September  28,  1885,  with  a  previous  history  of 
gonorrhoea  and  alcoholism.  He  complained  of  pain  beneath  the 
sternum,  cough  and  expectoration,  dyspncea  and  vomiting.  Pulse 
120  and  weak. 

On  examination,  signs  of  broncho-pneumonia  were  noted  in  both 
lungs,  with  enlargement  of  superficial  veins  over  anterior  portion  of 
the  chest.  Stridor  and  orthopnoea  supervened,  with  ursemia.  Dilata- 
tion of  left  pupil.  An  aneurism  of  the  arch  was  diagnosticated. 
The  patient  was  put  on  the  iodides,  but  succumbed  in  less  than  ten 
days,  during  an  attack  of  dyspnoea.  At  the  post-mortem  examination 
a  sacculated  aneurism  the  size  of  a  hen's  egg  was  found  projecting 
from  the  posterior  portion  of  the  transverse  arch,  just  beneath  the 
origin  of  the  innominate,  the  opening  into  the  sac  being  only  three- 
eighths  of  an  inch  in  diameter.  The  sac  had  pressed  on  the  trachea, 
the  right  side  more  especially,  eroding  its  rings.  Both  lungs  had 
deposits  that  looked  like  gummas.  The  sac  had  not  ruptured.  The 
cause  of  death  was  ascribed  to  the  broncho-pneumonia,  which  may 
have  been  due  to  retained  bronchial  secretion,  to  paresis  of  the 
pneumo-gastric,  or  to  chronic  diffuse  nephritis,  of  which  there  was 
ample  post-mortem  evidence.  This  case  is  remarkable  in  that,  with 
so  few  signs,  this  small  aneurism  was  made  out  during  life.     The 


256  True  Aneurisms 

diagnosis  was  based  on  the  tracheal  ini]:)lication,  broncho-pneumonia, 
and  uneven  dilation  of  pupils,  backed  by  a  syphilitic  history. 

Case  LXXXIV.  Aneurism  of  the  Transverse  Portion  of  the  Arch, 
Rupture  of  the  Sac;  Internal  Hemorrhage. — J.,  40,  France,  agent, 
was  admitted  to  hospital  July  31,  1883.  with  symptoms  of  dysphagia, 
dyspncea  and  difficulty  in  retaining  food.  Suspicious  looking  ulcer 
on  legs.  Pulse,  132.  temp.  98.  resp.  32.  Patient  died  four  days  after 
admission  in  a  suffocative  attack,  which  lasted  about  an  hour  and 
a  half.  At  the  post-mortem  examination  it  was  found  that  an 
aneurismal  sac  had  developed  from  the  superior  and  posterior  aspect 
of  the  transverse  part  of  the  arch,  the  innominate  and  left  common 
carotid  being  involved.  The  sac  had  pressed  on  the  trachea  and 
oesophagus,  and  there  was  in  it  an  orifice  1x3^  inches  in  diameter 
leading  from  the  sac.  The  stomach  contained  about  40  ounces  of 
blood  with  clots.  In  this  instance  no  diagnosis  was  made  during  life. 
Death  was  due  to  internal  hemorrhage. 

Case  LXXXV.  Ajiairism  of  the  Descending  Part  of  the  Arch; 
Death  by  Strangulafioi  from  Pressure  on  the  Trachea. — A  male  of 
27,  saddler  by  occupation,  entered  the  hospital  Nov.  2,  1882. 

He  had  a  cough,  dyspnoea,  paroxysmal  asthma,  and  tracheal  ob- 
struction, with  cyanosis.  Respiration  stridulous,  rough  and  pro- 
longed. A  prominent  sternum  complicated  the  diagnosis,  and  led  to 
the  suspicion  of  enlarged  mediastinal  glands.  The  only  relief  ob- 
tained was  from  the  inhalation  of  oxygen. 

At  the  post-mortem  examination  there  was  found  an  aneurismal 
sac  the  size  of  a  pullet's  tg^,  given  off  from  the  upper  and  posterior 
part  of  the  descending  aorta,  the  left  common  carotid  and  left  sub- 
clavian being  also  involved.  The  lower  margin  of  the  sac  had  com- 
pressed the  trachea,  causing  the  embarrassed  respiration.  The 
aneurism  was  not  recognized  during  life.  Cause  of  death,  strangu- 
lation. 

In  aneurism  of  the  descending  arch,  pain  is  a  most  prominent 
symptom.  The  pressure  signs  are  less  noteworthy.  There  is  some- 
times a  severe  burning  or  aching  pain  near  the  spine  in  the  entire 
scapular  region.  There  may  also  be  intercostal  neuralgia.  The  sac 
mav  press  on  the  left  bronchus,  which  may  obliterate  the  pulse  in 
the  abdominal  aorta,  or  delay  pulsation  in  the  arteries  of  the  lower 
extremities. 

The  sac  mav  erode  and  destroy  portions  of  the  ribs  and  eat 
away  the  bodies  of  several  dorsal  vertebrae.     One  of  the  most  con- 


True  Aneurisms  257 

stant  signs  in  disease  of  this  part  of  the  arch  is  severe  pain,  striking 
through  from  the  third  left  interspace  or  fourth  rib  to  the  body  of 
the  scapula.  Other  signs  are  cough,  paroxysmal  asthma,  dulness  on 
percussion,  evidences  of  pressure  on  the  trachea,  and  possibly  pain 
in  the  epigastrium.  There  is  usually  a  fixed  pain,  occasionally  a  pul- 
sation in  the  scapular  or  epigastric  region.  The  left  chest  wall  may 
be  expanded. 

CASE  LXXXVI.  Aneurism  of  the  Descending  Part  of  the 
Arch;  Death  due  to  Urccmia. — A  laborer,  34,  entered  the  hospital 
June  8,  1878,  complaining  of  a  pain  in  the  back,  that  had  lasted  a 
year.  He  also  had  epigastric  pain,  tenderness  in  the  lumbar  region, 
tumidity  of  the  abdomen,  and  mucous  evacuations.  He  died  of 
urjemia. 

At  the  post-mortem  examination  a  large  aneurismal  sac  five 
inches  in  greatest  diameter,  and  extending  upwards  six  inches,  was 
found  behind  the  descending  arch.  It  was  adherent  to  the  body 
of  the  fourth  dorsal  vertebra,  and  had  destroyed  the  bodies  of  the 
tenth  and  eleventh  dorsals.  The  necks  of  the  ninths  tenth  and 
eleventh  ribs  were  eroded.  No  positive  diagnosis  appears  to  have 
been  made  during  life.  The  aneurismal  sac  was  pretty  well  filled 
with  laminated  fibrine  and  had  not  ruptured.  Even  in  this  case  of 
a  large  aneurism  the  tendency  to  spontaneous  cure  was  noteworthy. 

Case  LXXXVII.  Aneurism  of  the  Descending  Arch;  Rupture 
into  the  Trachea;  Death  from  Internal  Hemorrhage. — A  male  of 
46  was  admitted  to  the  hospital  on  September  19,  1872,  with  the 
following  symptoms  and  physical  signs :  Cough,  expectoration,  pul- 
monary emphysema,  flatness  over  left  side  down  to  fourth  rib. 
Below  fourth  rib,  resonance  with  loud  blowing  sound.  Bronchial 
breathing.  Heart  hypertrophied  and  beating  tumultuously.  No 
valvular  murmurs.  No  emaciation.  These  physical  signs  were 
attributed  to  phthisis. 

The  patient  died  of  internal  hemorrhage  and  at  the  post-mortem 
examination  the  following  facts  were  disclosed.  The  upper  part  of 
the  left  pleural  cavity  was  occupied  by  an  aneurismal  sac  the  size  of 
one's  closed  fist.  It  sprang  from  the  inner  and  descending  part  of  the 
arch  and  grew  backwards.  Rupture  of  the  sac  into  the  trachea  had 
taken  place.  The  left  lung  was  crowded  down  by  the  sac.  and  that 
portion  nearest  the  latter  contained  puriform  liquid.  Diagnosis 
not  made. 

Sometimes  aneurisms  of  the  thoracic  aorta  may  develop  below 


258  True  Aneurisms 

tiic  arch.  They  are  apt  to  be  of  large  size,  and  erode  dorsal  verte- 
brae, as  the  following  case  indicates. 

Case  LXXXFIII.  Aneurism  of  the  Descending  Thoracic  Aorta; 
Death  frvni  Internal  Hemorrhage. — A  glass  cutter,  aged  41,  was  ad- 
mitted to  the  hospital  Aiay  i,  1879.  He  stated  that  a  pain  about  his 
heart  had  kept  him  from  work.  There  was  also  pain  to  the  inside 
of  the  left  scapula..  Insomnia.  Patient  unable  to  lie  on  left  side. 
Lower  part  of  chest  expanded. 

On  examination,  a  pulsation  was  seen  and  felt  at  the  lower  and 
inner  margin  of  the  left  scapula.  At  this  point  there  was  a  double 
murmur.     The  patient  died  of  internal  hemorrhage. 

At  the  post-mortem  examination  it  was  found  that  a  large 
aneurismal  sac  had  developed  from  the  upper  part  of  the  descending 
aorta  and  had  ruptured  at  the  lower  and  posterior  portion.  It  con- 
tained 90  ounces  of  serum  and  clots,  and  had  eroded  the  bodies  of  the 
fifth,  sixth,  seventh  and  eighth  dorsal  vertebrae ;  also  the  fifth,  sixth 
and  seventh  ribs,  cutting  the  latter  in  two. 

Aneurisms  of  the  abdominal  aorta  are  usually  just  below  the 
diaphragm,  near  the  coeliac  axis,  and  above  the  superior  mesenteric 
artery.  The  sac  may  project  in  any  direction.  If  it  push  forward, 
pulsation  may  be  felt  below  the  ensiform  cartilage,  usually  to  the 
left  of  the  median  line.  Palpation  will  detect  it  if  there  is  any  ex- 
pansile pulsation.  In  these  aneurisms,  however,  such  pulsation  is 
not  always  present.  Or  if  there  is  pulsation,  it  may  come  from 
a  tumor  beneath  the  vessel  or  above  it.  Besides,  pulsation  of  the 
abdominal  aorta  is  very  common  in  nervous  people  with  vaso-motor 
disturbances. 

If  the  tumor  projects  upwards  it  may  attain  considerable  size 
without  being  detected.  The  chief  symptoms  are  subjective.  Pains 
of  an  annoying  character  referred  to  the  spine  may  radiate  into  the 
chest  or  down  through  the  abdomen,  but  they  may  be  intermittent. 
The  sac  may  displace  the  internal  organs,  such  as  the  kidneys.  It 
ma\-  press  on  the  common  bile  duct,  or  on  the  cseliac  axis  and  its 
branches.  Small  aneurisms  sometimes  form  on  the  branches  of  the 
abdominal  aorta,  the  splenic,  superior  mesenteric  and  hepatic  arteries. 
Sometimes  the  superior  mesenteric  is  obstructed  by  embolism  or 
thrombosis,  and  hemorrhage  and  infarction  of  the  intestines  may  be 
the  result.  The  chief  symptom  is  pain  or  numbness.  It  may  be 
referred  to  the  back  or  front.  Uusually  there  is  a  fixed  pain  in  the 
epigastric  region. 

Inspection  shows  a  rounded  tumor  that  may  have  an  expansile 


True  Aneurisms  259 

pulsation  and  ilirill.  Auscultation  gives  a  diastolic  or  systolic  mur- 
mur, or  both.  The  femoral  and  radial  pulses  may  be  delayed. 
Pulsating  tumors  of  the  stomach,  liver  or  pancreas  are  mobile,  and 
the  pulsation  disappears  to  a  considerable  extent  when  the  patient 
is  put  into  the  knee-elbow  position. 

Case  LXXXIX.  Aneurism  of  the  Abdominal  Aorta;  Rupture 
into  the  Retro-Peritoneal  Region. — A  male  of  25,  addicted  to  alcohol, 
with  a  probable  history  of  syphilis,  was  admitted  to  hospital  October 
4,  1876,  with  the  following  symptoms :  Dulness  in  the  small  of  the 
back,  a  sense  of  heaviness  on  both  sides.  Flying  pains  about  the 
body.  Pain  in  the  left  thigh  extending  to  ankle.  Pulsation  in  left 
lumbar  region,  and  in  the  middle  of  the  abdominal  cavity.  Thrill 
and  bruit  below  the  ensiform  cartilage,  and  over  the  lower  dorsal 
spines.     The  diagnosis  was  correctly  made. 

At  the  post-mortem  examination  it  was  found  that  the  aneuris- 
mal  sac  extended  from  the  last  dorsal  to  the  last  lumbar  vertebra. 
Its  dimensions  were  7x43^  inches,  and  it  had  an  hour  glass  con- 
striction at  the  center.  The  opening  from  the  aorta  was  just  below 
the  cteliac  axis.  The  body  of  the  last  dorsal  vertebra  was  eroded. 
The  escaped  blood  formed  a  tumor  the  size  of  a  child's  head  behind 
the  peritoneum.  Possibly  a  spiculum  from  the  eroded  vertebra  tore 
open  the  sac. 

Case  XC.  Aneurism  of  Abdominal  Aorta;  Rupture  into  the 
Peritoneum.  Death  froifi  Internal  Hcemorrhage. — A  male  of  40 
entered  the  hospital  December  i,  1882,  complaining  of  pain  in  the 
epigastrium,  right  hyperchondrium,  both  groins  and  stomach,  for 
which  he  was  taking  opiates.  His  urine  and  stools  were  dark 
colored.  On  examination,  a  pulsating  tumor  was  found  in  the 
epigastrium.  Death  occurred  from,  rupture  of  the  aneurismal  sac 
into  the  peritoneum.  The  sac  itself  was  only  two  inches  in  diameter. 
It  sprang  from  the  front  of  the  aorta  and  involved  the  caeliac  axis 
and  superior  mesenteric  artery.  The  rupture  took  place  just  above 
the  level  of  the  pancreas.  Four  ounces  of  blood-clot,  and  four  of 
bloody  serum,  were  found  in  the  peritoneal  cavity.  As  the  sac  was 
small,  the  symptoms  prior  to  rupture  were  not  pronounced. 

Case  XCI.  Aneurism  of  the  Abdominal  Aorta.  Death  from 
Internal  Hcemorrhage. — A  male  of  47,  car  driver,  was  admitted  to 
hospital  January  27,  1887,  with  a  bubo  and  gonorrhoea.  He  de- 
scribed himself  as  a  moderate  drinker.  Shooting  pains  down  the 
thighs,  legs  and  in  the  abdominal  cavity  were  ascribed  bv  him  to  a 
severe  cold  bought  on  by  exposure  to  cold  and  wet.     The  pain  in 


2C)0  True  Aneurisms 

tlie  lower  extremities  was  found  to  be  contincd  to  the  left  sciatic  and 
crural  nerves.  The  patient  died  of  internal  hemorrhage,  and  at  the 
post-mortem  it  was  found  that  a  small  sacculated  aneurism,  rising 
from  the  anterior  surface  of  the  abdominal  aorta,  just  below  the 
coeliac  axis,  had  eroded  the  underlying  vertebra  and  that  a  spicu- 
lum  of  bone  had  lacerated  the  sac.  causing  internal  hemorrhage  and 
death.  Nodules  resembling  gummas  were  found  in  the  lungs.  There 
were  also  copper-colored  scars  on  the  legs. 

Aneurisms  of  the  pulmonary  artery  are  comparatively  rare,  and 
in  half  the  cases,  are  probably  associated  with  congenital  disease. 
On  the  other  hand,  aneurism  of  the  branches  of  the  artery  are  com- 
mon, if  we  include  under  this  name  the  minute  aneurisms  found  in 
tuberculosis  phthisis.  Rupture  of  these  aneurisms  in  phthisis  often 
causes  death  from  hemorrhage.  The  aneurism  begins  as  a  peri- 
arteritis and  endarteritis.  This  matter  does  not  interest  us  at 
present.  Generally,  dilatations  of  the  pulmonary  artery  are  due  to 
obstruction  of  the  branches  of  this  vessel,  or  constriction  at  their 
orifices.  This  latter  is  very  rare.  The  following  is  an  example  of  the 
latent  variety. 

Case  XCII.  Aiiciirisiii  of  the  Puliiionary  Artery.  Death  from 
Embolism. — C.  A.,  widow  of  50,  entered  the  hospital  August  4, 
1881,  with  a  history  of  rheumatism,  anaemia  and  cyanosis.  She  was 
also  found  to  have  dyspnoea  and  oedema  of  the  extremities.  Pulse 
weak,  irregular,  intermitting  every  fourth  beat.  Heart  enlarged. 
Loud  blowing  murmur  at  the  base,  and  diffused  over  nearly  all  the 
precordial  space,  but  most  distinct  between  nipple  and  sternum. 
First  sound  rough.  Ths  patient  died  suddenly.  At  the  post-mortem 
examination  the  pulmonary  artery,  witli  its  right  and  left  branches, 
was  found  considerably  dilated.  On  the  right  pulmonary  was  an 
aneurismal  sac  the  size  of  a  duck's  tgg,  with  solid  contents.  On  the 
left  pulmonary,  at  a  corresponding  point,  was  another  aneurism  of 
about  the  same  size.  The  cause  of  death  was  supposed  to  have 
been  embolism  in  one  of  the  pulmonary  arteries,  by  w^hich  the 
blood  was  rapidly  dammed  back  on  the  heart. 

In  thoracic  and  abdominal  aneurisms  I  am  disposed  to  think, 
from  my  experience,  that  surgery  has  been  unsuccessful,  and  that, 
distal  pressure,  ligation,  introduction  of  foreign  bodies  like  wire, 
injection  of  fluids,  as  the  perchloride  of  iron,  application  of  electric- 
ity, or  compresses,  achieve  but  temporary,  if  any,  improvement,  while 
medical  remedies  offer  far  better  hopes  for  the  unfortunate  patient. 

Of  all  considerations  to  my  mind,  the  first  is  rest;  the  second  is 


True  Aneurisms  261 

restriction  in  food  and  drink;  the  third,  a  cardiac  sedative.  Our  ob- 
ject is  to  coagulate  the  blood,  remembering  that  this  is  the  remedy 
adopted  by  nature  in  curing  aneurisms,  which,  as  Case  No.  LXXV. 
shows,  may  be  cured  spontaneously  if  the  tumors  are  small.  First 
in  importance  is  rest  in  the  recumbent  position.  It  causes  relaxation 
of  the  sac,  and  favors  slow  coagulation,  which  may  lead  to  solidifica- 
tion of  the  fibrine  in  layers.  Second  in  importance  is  diet.  The 
Tufnell  method  is  perfectly  legitimate.  It  is  a  modification  of  Val- 
salva's, who  treated  his  patient  by  frequent  bleedings,  and  of  Bell- 
ingham's,  whose  was  a  mild  starvation.  Tufnell's  method  allows 
the  patient,  for  breakfast,  two  ounces  of  milk  or  cream,  and  two 
ounces  of  wheat  bread  with  butter.  For  dinner,  three  ounces  of  meat, 
three  ounces  of  potatoes  or  bread,  four  ounces  of  water  or  claret. 
For  supper,  four  ounces  of  bread  and  two  ounces  of  milk  or  tea. 
In  all,  twelve  ounces  of  solids  and  eight  ounces  of  liquids  are  given. 
Tufnell  reported  ten  cases  successfully  treated  in  this  way.  His  ob- 
ject was  to  reduce  the  volume  of  blood,  while  the  fibrine  was  in 
creased.  If  improvement  is  attained,  it  should  appear  in  from  four 
to  six  weeks.  Iodide  of  potassium  or  sodium  are  drugs  that  may 
be  used.  Commence  with  five  grains  three  times  a  day  and  increase 
to  fifteen  or  twenty ;  or  iodine  in  other  forms  may  be  used.  Stop 
only  when  there  are  symptoms  of  iodism.  The  treatment  may  be 
continued  for  months  and  years.  When  there  is  a  visible  tumor, 
cold  may  be  applied  by  means  of  Letters  tubes,  part  of  the  bag  rest- 
ing on  the  aneurism.  Apply  at  intervals,  at  first,  and  then  continu- 
ously ;  cold  tends  to  relieve  the  pain  and  reduce  the  sac.  After 
a  thorough  course  of  two  months,  the  patient  may  gradually  resume 
his  work,  if  the  symptoms  warrant  it.  In  the  case  of  a  cure,  the 
tumor  will  remain,  but  it  will  shrink  into  a  hard  ball.  Among  the 
remedies  that  are  useful  is  aconite  in  from  one  to  two  minims  of 
the  tincture,  increased  gradually  to  four  or  five  minims  every  four 
hours.    Digitalis  is  dangerous ;  it  may  burst  an  aneurism. 

Broadbent  has  reported  a  case  of  aortic  aneurism  that  lived  ten 
years,  and  Hayden  a  case  of  abdominal  aneurism  that  lived  eleven 
years.  There  is,  therefore,  some  encouragement  in  the  medical 
treatment  of  aneurism,  though  aneurisms  of  large  size  do  not  afford 
us  much  ground  for  hope  of  a  cure. 

The  following  is  a  summary  of  the  important  points  to  be  re- 
membered : 

In  the  diagnosis  of  thoracic  and  abdominal  aneurisms,  no  sisrns 


262  True  Aneurisms 

are  pathognomonic,  but  botli  subjective  and  objective  phenomena 
arie  to  be  considered. 

Success  in  the  treatment  of  these  aneurisms  depends  on  their 
early  recognition,  as  large  aneurisms  are  pretty  surely  fatal,  either 
from  rupture  or  pressure. 

Syphilis,  gout  and  alcoholism  are  causal  factors,  so  that  the 
importance  of  combating  them  cannot  be  overestimated.  Unfortu- 
nately, physicians  do  not  sufficiently  recognize  the  agency  of  these 
conditions,  and  are  apt  to  be  especially  unsuccessful  in  detecting 
syphilis. 

The  larger  aneurisms,  whether  thoracic  or  abdominal,  have  thus 
far  baffled  the  best  efforts  of  modern  surgeons,  while  medical  treat- 
ment has  at  least  insured  a  longer  lease  of  life  and  offers  greater 
chances  of  cure,  if  treatment  is  undertaken  early. 


ClIAl'TKR    XXIII. 

AORTITIS. 

Most  persons  have  aortic  disease  after  middle  life,  and  many  at 
an  earlier  period.  This  much  was  probably  known  centuries  ago ; 
for  wherever  post-mortem  examinations  were  allowed  and  practised, 
aortic  lesions  must  have  been  readily  recognized  by  the  naked  eye. 
It  is  not  improbable  that  they  were  known  before  the  Christian  era. 
Certainly  Galen's  presumed  contemporary,  Aretaeus,^  the  Cappa- 
docian,  alluded  to  them,  and  he  is  supposed  to  have  flourished  in 
the  second  century.  Not  to  mention  other  medical  writers,  Mor- 
gagni-  described  some  phases  of  them.  But  up  to  the  time  of 
Scarpa^  they  were  so  little  understood  that  the  most  characteristic 
type  of  chronic  aortitis,  the  cylindrical  or  fusiform  (false  aneurism), 
had  not  been  diiTerentiated  from  the  sacculated  or  true  aneurism. 

There  are  two  principal  division  of  aortitis,  the  acute  and  chronic 
(known  also  as  the  subacute),  for  there  is  no  pathological  or  clinical 
line  of  distinction  that  can  be  profitably  drawn  between  the  latter 
two. 

So  far  as  etiology  and  pathology  are  concerned,  these  matters  are 
tolerably  well  understood,  but  the  clinical  features  of  aortitis  have 
elicited  sharp  discussion  since  Portal's  time  (1803),  and  as  regards 
the  acute  form,  without  making  much  progress.  For  many,  in- 
deed most,  clinicians  do  not  believe  that  it  can  be  recognized,  in  any 
locality,  even  under  the  most  favorable  circumstances  intra  vitam, 
independent  of  traumatism.  On  the  other  hand,  in  some  instances, 
the  chronic  form,  as  seen  in  the  ascending  arch  of  the  aorta  in  the 
variety  known  as  Hodgson's  Disease,  can  sometimes  be  differentiated 
with  little  difficulty,  as  is  shown  in  Case  XCVI.  As  simple  dilata- 
tion of  the  aorta  may  not  be  inflammatory,  it  is  considered  separately. 

There  are  two  varieties  of  acute  aortitis,  the  acute  primary, 
where  it  constitutes  the  sole  inflammatory  lesion,  and  the  acute 
secondary,*"  which  is  invariably  associated  with  the  chronic  form,  as 
exemplified  by  such  chronic  manifestations  as  fibroid  deposits,  fatty 


^Aretaeus,  On  the  Causes  and  Symptoms  of  Acute  Disease,  London,  1856, 
Book  II,  p.  445.      (Trans.) 

^  Morgagni,  On  the  Seat  and  Causes  of  Disease,  Vol.  I,  p.  389.     (Trans.) 
^  Scarpa,    Reflections   et     Observations     Anatomico-chirurg-icales,     Paris, 

1809,  p.  I. 
*  Huchard. 


264  Aortitis 

degeneration.  artcrioscUrosis.  atheroma,  or  a  combination  of  them. 

On  the  other  hand,  the  primary  acute  form  includes  infiltration 
of  the  walls  of  a  vessel  with  serum,  fibrin  or  lymphoid  corpuscles ; 
or  suppuration,  ulceration,  formation  of  granulation  tissue,  or  even 
gangr'jne  ;  making  it  easy  to  separate  it  from  the  chronic  form,  on 
a  purely  pathological  basis. 

The  acute  secondary  form  is  found  only  in  association  with 
chronic  processes,  to  which  it  bears  the  same  relation  as  the  acute 
manifestations  of  typical  rheumatic  gout  bear  to  the  chronic  enlarge- 
ment of  the  joints,  of  which  they  are  part ;  for  the  two  processes 
work  together  simultaneously  within  the  affected  area. 

Acute  aortitis  is  also  occasionally  caused  by  tuberculosis  or 
syphilis,  both  of  which  are  known  to  have  special  affinities  for  ar- 
teries. It  is  also  due  to  infections,  such  as  malignant  endocarditis  and 
puerperal  fever ;  possibly  to  eruptive  fevers,  and  probably  to  acute 
gout  or  other  diatheses  or  intoxications.  It  may  originate  in  the 
walls  of  the  vessel,  or  be  a  metastatic  deposit,  or  an  extension  from 
adjacent  parts,  as  in  pericarditis,  possibly  in  pieuritis  or  pneumonia. 
Case  XCIII  appears  from  prima  facie  evidence  to  be  an  example  of 
the  latter  character,  though  it  is  not  altogether  conclusive  to  my 
mind.  I  give  it  because  out  of  915  post-mortem  examinations  of 
which  I  have  clinical  notes,  it  is  the  only  one  I  have  found. 

Case  XCIII.  Articular  Rhenmatisni ;  Malignant  Endocarditis; 
Ulcer  of  the  Aorta. — R.  56,  male,  was  admitted  to  hospital  May  21, 
188 1.  Four  weeks  previously  he  had  his  first  attack  of  articular 
rheumatism,  which  involved  the  large  joints  and  left  him  feeble  and 
scarcely  able  to  stand.  Convalescence  began  in  three  weeks,  but 
d\  spepsia,  headache,  epigastric  distress  and  irregular  chills,  followed 
by  fever  and  sweating,  supervened.  There  was  never  at  any  time 
oedema,  but  the  urine  was  scanty  and  contained  a  trace  of  albumin. 

On  examination  a  double  mitral,  and  later  a  double  aortic  mur- 
mur were  detected.  Pulse  irregular.  Ten  days  after  admission 
pne-r.iior'-'     '•'     n   and  caused  deatli  on   the  sann^  da; 

A  diagnosis  of  probable  ulcerative  endocarditis  had  been  made. 
At  the  autopsy,  which  unfortunately  was  for  some  reason  delayed 
and  was  confined  to  but  a  few  organs,  blood  was  found  in  the  peri- 
cardium. For  an  ulcer  had  eaten  through  the  substance  of  the  heart 
from  the  aortic  to  the  mitral  valves,  and  blood  was  extravasated 
beneath  the  endocardium.  There  was  also  an  ulcer  in  the  aorta.  As 
old  infarcts  and  puckerings  were  found  in  the  spleen,  it  is  probable 
that  there  had  been  a  benign  endocarditis  at  some  time,  and  that  the 


Aortitis  265 

malignant  or  ulcerative  character  was  a  superadded  manifestation. 
This  case  is  obviously  incomplete  in  many  ways,  but  it  appears  none 
the  less  to  fall  into  the  category  with  Andral's  single  case''  and  the 
four  of  Lebert/',  Spengler/  Schutzenberger,^  and  Leudet,"  respec- 
tively. 

In  a  case  of  aortic  and  mitral  disease  Spengler  found  a  small 
.abscess,  the  size  of  a  hazel  nut.  just  above  the  semi-lunar  valves. 

Schutzenberger  also  found  in  his  case  an  abscess  the  size  of  a 
nut  at  the  origin  of  the  aorta,  and  between  the  middle  and  internal 
coats.     There  was  an  associated  pericarditis. 

In  Leudet's  case,  likewise,  there  was  an  abscess  fthe  size  of  a 
filbert)  between  the  internal  and  middle  coats,  communicating  by 
.an  orifice  the  diameter  of  a  small  pea  with  the  lumen  of  the  aorta. 
In  all  these  instances  there  were  the  clinical  evidences  of  a  purulent 
infection. 

In  tuberculosis  the  aorta  may  also  be  the  seat  of  acute  or  chronic 
tubercular  deposits.  A  number  of  such  instances  have  been  de- 
scribed by  Blumer.^"  Syphilis  of  the  aorta  has  also  been  recognized 
Iby  n'jmerous   clinicians. 

So  far  as  the  prognosis  is  concerned,  there  is  always  a  bare 
probability  that  an  acute  attack  may  end  in  recovery.  That  such 
an  event  is  possible  is  shown  in  Case  XCIV,  where  more  or  less 
<:icatnzation  was  found  in  the  aorta ;  but  inasmuch  as  the  causes, 
so  far  as  we  know  with  certainty,  are  apt  to  be  chronic  affections  like 
■syphilis,  tuberculosis  and  gout,  the  disease  is  most  likely  to  assume 
the  chronic  form.  Even  if  the  acute  variety  is  not  purulent,  but  is 
represented  by  an  infiltration  with  fresh  plastic  matter  (the  so-called 
gelatiniform  plaques),  degeneration  will  in  time  occur,  ulcers  may 
develop,  or  plates  of  atheroma  of  a  bony  hardness,  so  that  the 
acute  will  pass  by  slow  transition  into  the  subacute  or  chronic  form. 
Of  course,  in  cases  associated  with  malignant  endocarditis,  or  a 
purulent  infection,  a  fatal  termination  is  to  be  expected. 

Acute  aortitis  was  first  brought  prominently  to  the  notice  of 
the  profession  by  PortaP^  in  1803,  but.  as  already  stated,  widely 
divergent  ideas  as  to  its  clinical  aspects  have  prevailed  about  it  since 
"his  day. 

"Andral,  Path.  Anat.,  Vol.  II,  p.  243. 

"  Lebert.  Krankhcitcn  der  Artericn.  J^ircho-iv's  Path,  and  Thera.,  1867, 
"Vol.    II.    s.    347. 

'  Spengler.  Virchoxi-'s  Archk:,  IX,  1852.  s.  166. 

'  Schutzenberg-er.  Archives  Generalcs.  1861,  II,  o.  581. 

'  Leudet.  Archk:  Gen.  de  Med..  Ser.  5.  18,  p.  581. 


266  Aortitis 

In  1824  Bertiii  and  Bouillaiul'-  reported  sixteen  cases,  but  the 
changes  seen  at  the  autopsies  were  not  typical,  and  apparently  the 
reddened  condition  of  the  aortas,  on  which  they  laid  so  much  stress, 
was  due  to  post-mortem  inhibition.  Indeed  Huchard,^-'  a  firm 
believer  in  acute  aortitis  as  a  disease  capable  of  being  recognized  at 
the  bedside,  has  accepted  only  one  of  these  cases  as  conclusive. 

In  1837  Bizot^^  published  three  cases,  claiming  that  the  signs 
were  anasarca,  intense  fever,  prostration  and  delirium,  while,  as  a 
matter  of  fact,  oedema  and  delirium  have  no  necessary  connection 
with  acute  aortitis.  His  first  case  was  probably  one  of  pericarditis, 
and  the  last  two  of  Bright's  Disease,  which  was  unknown  at  that 
time. 

These  misconceptions,  however,  were  in  due  time  pointed  out  by 
Laennec.'^  who  showed  that  inflammation  of  a  vessel  w^as  to  be 
distinguished  from  post-mortem  inhibition,  and  that  among  its 
characteristics  were  swelling,  thickening  and  a  development  of 
new  vessels. 

In  detail  the  pathological  changes  are  as  follows :  The  signs  of 
inflammation  arc,  as  a  rule,  seen  first  in  the  internal  coat,  which  be- 
comes reddened,  and  later  takes  on  a  pellucid  grayish  or  grayish- 
yellow  color ;  then  the  inflamed  part  swells  and  is  raised  up  above 
the  level  of  the  surrounding  tissue.  These  elevated  plaques  are  soft 
and  have  a  translucent  appearance — whence  they  are  known  as 
gelatbuform  plaques — and  they  may  either  remain  of  a  gray  or 
yellowish-gray  tint  or  become  rose  colored.  They  are  infiltrated 
with  serum,  fibrine  or  lymphoid  corpuscles,  perhaps  an  admixture 
of  two  or  more  of  them  ;  which  accounts  for  the  variations  in  their 
color.  After  the  plaques  soften,  they  may  fungate  and  leave  ero- 
sions. The  outer  coat  is  eventually  involved,  the  middle  coat,  which 
contains  clastic  plates  and  fibres  and  smooth  muscle  tissue,  suffering 
least. 

Acute  inflammation  is  in  a  measure  produced  bv  injuries  caus- 
ing hyperdistension,  as  in  the  arch  of  the  aorta,  where  the  full  force 
of  the  systole  is  felt ;  but  even  in  acute  aortitis,  as  it  is  seen  in  the 
arch,  when  intense  pressure  has  been  brought  to  bear  on  the  walls 
of  the  vessel  by  violent  physical  exercise,  there  is  apt  to  be,  and 


'"  Blumer,  /int.  Journal  of  the  Med.  Soc.  1899,  n.  s.  cxvii,  pp.  19-25. 
"  Portal.  Cours  d'Anat.  Medicale,  Vol.  Ill,  1803,  p.  144. 
"  Benin  and  Bouillaud,  Treatice  des  Maladies  du  Coeiir,  et  dcs  gros  vais- 
seaux.  1824.  p.  4. 

"  Hiichard,  Maladies  du  Canr,  etc.,  1893,  p.  445,  ct  scq. 
"  Bizot,  Soc.  Med.  d'Observ.,  1837,  p.  332. 


Aortitis  267 

perhaps  alwa}'s  is,  some  vice  in  the  circulatory  fluid  which  trans- 
forms a  simple  dilatation  intfj  an  af>rtitis  with  dilatation. 

While,  therefore,  there  is  no  doubt  that  aortitis  occurs  as  a  path- 
ological fact,  clinicians  have,  as  stated,  been  disposed  to  give  it  a  wide 
berth.  Even  Jaccoud"^''  has  differecl  from  many  of  his  confreres  of 
the  French  school,  and  stated  that  there  are  no  symptoms  by  which 
the  acute  can  be  separated  from  the  chronic  form ;  while  Von 
Schroetter^"  denies  that  it  is  an  independent  disease,  with  distinctive 
signs  and  typical  course. 

Accordmg  to  Peter,^*  the  clinical  diagnosis  turns  on  palpitation, 
difficult  breathing,  local  pain,  a  burning  sensation  under  the  sternum 
and  active  pulsation  of  the  aorta,  but  he  is  unable  to  distinguish  it 
from  angina  pectoris.  Ouain^''  has  made  the  signs  acute  substernal 
pain,  with  oppression,  palpitation,  quick  and  feeble  pulse,  elevation 
of  temperature  and  a  harsh  systolic  murmur  at  the  seat  of  inflam- 
mation and  transmitted  up  the  vessel.  Huchard^"  says  that  if  the 
patient  has  the  characteristic  dyspnoea,  with  a  substernal  sense  of 
burning  or  tearing,  one  thinks  of  aortitis,  and  if,  in  addition,  the  heart 
is  hypertrophied,  without  much  valvular  accentuation,  and  there 
is  a  double-bellows  murmur,  more  or  less  rude  in  quality,  the  diag- 
nosis is  easy.  To  him,  however,  the  acute  primary  form  has  three 
special  signs  (i)  labored  breathing,  (2)  pain,  and  (3)  syncopal  at- 
tacks. Unfortunately,  he  gives  no  illustrative  case  that  is  satisfac- 
tory. Certainly  in  the  vast  majority  of  cases  the  acute  stage  does 
not  reveal  itself  by  any  pathognomonic  signs. ^°  In  the  absence  of 
proof,  therefore,  that  acute  aortitis  is  capable  of  demonstration  dur- 
ing life,  it  is  useless  to  discuss  its  treatment. 

Chronic  aortitis  is  a  peculiar  affection,  combining,  as  already 
stated,  acute  manifestations  (the  acute  secondary  of  Huchard)  and 
the  chronic  ;  both  of  them  progressing  side  by  side.  The  causes  are 
diatheses  such  as  gout,  or  intoxications  like  lead  and  alcohol,  while 
hypertension  from  over-work,  perhaps  from  tobacco,  together  with 
senility,  are  contributing  factors.  The  chronic  ma\'  supervene  on 
the  acute  process,  itself  induced  by  infections  like  typhoid  or  the 
eruptive  fevers. 

"  Whatever  causes  the  inflammation,  the  net  result  is  that  the 
vessel  w^all  gets  to  be  thickened,  less  elastic  and  less  vascularized. 
The  process  may  involve  the  orifices  of  the  branches,  which  are 
narrowed  and  stiffened,  and  if  the  disease  extends  become  obliter- 
ated. This  sometimes  occurs  to  the  orifices  of  the  coronary  arteries. 
The  loss  of  elasticitv  in  the  aorta,  infiltration  of  its  wall  and  narrow- 


268  Aortitis 

ing  of  the  calibre  of  its  branches,  inevitably  lead  to  dilatation,  unless 
it  is  checked  by  the  calcifying  process  (atheroma). 

Joseph  Hodgson,  in  his  prize  essay  {Diseases  of  the  Arteries  and 
Veins,  London,  1815),  appears  to  have  been  the  first  to  call  attention 
to  the  chronic  aortitis  especially  associated  with  the  peculiar  dilata- 
tion of  the  ascending  portion  of  the  arch  of  the  aorta  which  goes 
by  his  name.  It  is  also  known  as  the  cylindrical  or  fusiform 
aneurism. 

Hodgson's  description  of  it  holds  good  to-day.  He  says  it  is 
most  frequently  found  in  the  ascending  part  of  the  aorta,  the  vessel 
forming  a  huge  pouch,  usually  commencing  just  above  the  semi- 
lunar valves,  but  there  is  no  loss  of  continuity  in  the  vessel ;  in  fact, 
it  may  occupy  only  one  side  of  the  vessel.  His  subjective  signs  were 
dyspnoea,  palpitation,  syncopal  attacks,  and  copious  expectoration 
of  mucus.  As  an  objective  sign  was  the  small  and  intermittent 
pulse.  There  are,  however,  many  others.  Inasmuch  as  the  disease 
begins  with  an  endarteritis,  there  may  be  a  bellows  murmur,  pain 
if  there  is  pressure  from  dilatation,  prolongation  of  systole,  and 
cardiac  dilatation.  So  soon  as  the  aorta  is  dilated  it  is  also  elongated, 
and  the  right  subclavian  is  pushed  up.  If  the  patient  lies  on  the 
back  and  the  shoulder  is  elevated,  the  dilatation  can  be  felt. 

By  percussion  it  may  be  found  that  the  vessel  is  broadened ;  it  is 
normally  iy'2.  to  2  inches  wide  in  adult  males;  i  to  i^^  inches  in 
adult  females.  In  dilatation  the  right  margin  of  the  vessel  may  be  as 
much  as  53^  inches  from  the  median  line.  The  following  is  an 
illustrative  case : 

Case  XCIV.  Chronic  Aortitis  of  the  Ascending  Aorta;  {Hodg- 
son's Disease),  Stenosis  and  Insufficiency  of  the  Aortic  Valves; 
Chronic  Nephritis,  and  Meningitis. — W..  64,  male,  was  admitted  to 
hospital  July  8.  1882.  with  a  previous  history  of  alcoholism,  rheu- 
matism and  privation. 

He  complained  in  particular  of  a  sense  of  constriction  beneath 
the  sternum,  and  of  cough.  His  extremities  were  oedematous. 
Urine  was  found  to  be  scanty  and  albuminous,  containing  casts  of 
various  kinds.  Chronic  nephritis  was  a  constant  feature  of  the 
case.  On  auscultation  a  double  murmur  was  heard  at  the  base 
of  the  heart,  which,  from  the  post-mortem  findings,  may  have  been 

"  Laennec,  Dis.  of  the  Chest,  p.  743.  1838. 

''Jaccond,  Lecons  de   Clinique,   1884-5,   s.   117. 

"von  Schroctter,  Nothnagcl's  spec.  Path.  u.  Ther.,  XV,  Theil.  II. 

"  Peter.  Mai.  du  Cocur,  1883,  p.  776. 

"  Quain,  Diet,  of  Medicine,  1&S3. 

"  According  to  Douglas  Powell,  in  Pepper's  System,  Vol.  Ill,  p.  800. 


Aortitis  269 

due  to  endocarditis  of  the  semilunar  valves.  Apex  in  the  fifth  space 
and  one-half  inch  outside  of  the  nipple.  Among  other  notevi^orthy 
symptoms  during  his  illness,  vi'hich  lasted  fourteen  weeks,  v^ere 
irregular  pulse,  syncopal  attacks  at  night,  dyspnoea,  delirium  alter- 
nating with  hebetude,  and  at  the  last,  coma. 

At  the  post-mortem  examination  there  was  found  an  adherent 
pericardium,  and  aortic  stenosis  with  insufficiency  due  to  aortic  en- 
docarditis ;  while  the  aorta  represented  a  great  variety  of  changes, 
from  simple  inflammation  to  fatty  degeneration,  or  atheroma,  or  de- 
struction of  tissue  with  some  attempt  at  repair.  The  whole  arch 
was  notably  dilated  and  constituted  a  true  fusiform  or  cylindrical 
aneurism  {Hodgson's  Disease).  Both  kidneys  were  examples  of 
chronic  diffuse  nephritis,  one  being  much  contracted.  There  was 
thought  to  be  slight  cirrhosis  of  the  liver.  Ascites,  Chronic  cere- 
bral meningitis. 

This  case  presented  several  features  of  interest  from  the  point 
of  view  of  the  aortitis.  It  was  of  the  chronic  form,  illustrating  the 
acute  manifestations  often  seen  in  that  affection.  The  cicatrization 
also  demonstrated  that  nature  can  and  does  effect  some  sort  of  cure. 
But  there  was  no  evidence  that  any  of  the  signs,  subjective  or  objec- 
tive, belonged  to  the  aortitis,  which  contributed  little  if  anything  to 
the  fatal  result.  This  was  due  to  uraemia,  conjoined  with  meningitis, 
though  the  cardiac  difficulty  may  have  been  a  predisposing  factor. 
Even  the  substernal  constriction  was  relieved  by  stimulants.  It 
should  have  increased,  if  the  pain  had  been  due  to  aortitis. 

It  is  not  unlikely,  however,  that  the  diagnosis  could  have  been 
made,  if  special  attention  had  been  directed  to  the  matter.  Per- 
cussion would  in  all  probability  have  disclosed  an  increased  area 
of  dulnss  over  the  aorta;  it  would  have  been  found  that  the  aortic 
direct  murmur  was  carried  more  to  the  right  than  usual,  while  the 
aortic  endocarditis  and  the  elongated  heart  would  have  made  the 
dilatation  probable  or  possible  in  a  man  sixty-four  years  of  age. 
Nowadays  the  X-ray  would  have  shown  the  dilatation,  as  it  did  for 
me  in  the  following  case: 

Case  XCV.  Chronic  Aortitis;  Aortic  Endocarditis ;  Albu- 
minuria; Glycosuria;  Infrequent  Pulse. — R.,  a  retired  man  of  busi- 
ness, 64  years  of  age,  was  referred  to  me  in  May,  1899,  by  his  physi- 
cian, on  account  of  a  troublesome  epistaxis,  ascribed  to  arterial 
disease.  The  subjective  symptoms  were  shortness  of  breath,  occa- 
sional fainting  attacks ;  at  times  pain  over  the  heart,  sometimes  at 
the  apex,  sometimes  in  the  neck  or  joints.     Gouty  deposits  in  the 


270 


Aortitis 


finger  joints.  P\ilse  80,  intermittent.  Respiration  16.  Enlarge- 
ment of  the  superficial  veins  of  the  chest,  especially  on  the  right  side. 
Facies  arterio-sclerotica.  Double  bruit  over  the  aorta.  Loud  systolic 
nuirmur  with  first  sound,  propagated  up  the  great  vessels  and  with 
second  sound  radiating  to  the  right  and  also  down  the  sternum. 
No  mitral  murmur.    Heaving  impulse. 

The  apex  was  found  just  within  the  nipple  and  two  inches  below 
the  intermammillary  line.  The  loud  murmur  with  the  first  sound 
at  base  about  corresponded  with  an  area  5  inches  in  diameter,  ex- 


FiG.   40. 

tending  2/^2  inches  to  the  right  of  the  median  line  and  2  inches  to 
the  left  of  it.     By  fluoroscopy-^  this  area  threw  a  somewhat  dark 


^'  Prof.  Samuel  Lloyd  assisted  me  in  making  the  X-ray  picture,  which  I 
drew  on  the  fluorescent  screen,  and  on  the  same  day,  in  sending  a  copy  of  my 
fluorograph  to  his  physician,  I  wrote :  "There  appears  to  be  above  the  heart 
a  tolerably  well-defined  shadow  which  corresponds  to  the  aorta,  while  at  this 
point  I  find  a  double  bruit.  I  therefore  think  there  is  a  dilatation  of  the 
aorta,  probably  with  extensive  atheroma,  and  that  this  condition  causes  the 
aortic  double  sounds  primarily."  In  the  year  following  this  condition  was 
depicted  by  Cabot  (Physical  Diagnosis,  N.  Y.,  1900,  p.  172).  Cabot  believes 
that  dilatation  of  the  ascending  portion  of  the  arch  occurs  in  almost  every  case 
of  aortic  regurgitation. 


Aortitis  271 

shadow,  and  to  my  mind  indicated  a  fusiform  dilatation  of  the  aorta 
(ascending  portion  of  the  arch),  although  (see  Fig.  40)  the 
shadow  was  not  as  dark  as  1  have  seen  it  in  sacculated  aneurism. 
Examination  of  the  blood  showed  95  per  cent,  of  haemoglobin. 
Daily  amount  of  urine,  24  ounces ;  specific  gravity,  1025 ;  traces 
of  albumin ;  sugar,  2  per  cent. ;  hyaline  casts ;  urea,  6  grains  per 
ounce.  The  patient  took  a  course  of  baths  and  resistance  exercises 
at  Nauheim.  On  his  return  he  was  no  longer  short-winded,  but 
had  occasional  shooting  pains  over  the  heart.  Pulse  "^2,  one  inter- 
mission instead  of  four  per  minute.  Respiration  16.  Superficial 
veins  of  chest  not  so  prominent.  Murmur  the  same,  but  cardiac 
enlargement  diminished.  As  the  patient  contracted  a  rheumatic  at- 
tack on  his  return  voyage,  he  was  put  by  me  on  the  hot-air  treat- 
ment and  the  iodides  were  given. 

On  January  2,  1901,  the  examination  of  the  urine  was  as  follows: 
Specific  gravity,  1015  ;  amount,  33  ounces;  no  albumin;  no  sugar; 
traces  of  indican.  On  March  23,  1901,  the  patient  expressed  himself 
as  free  from  all  disagreeable  symptoms,  although  the  auscultatory 
signs  were  little  changed. 

The  X-ray  examination  was  made  for  the  purpose  of  determining 
between  a  true  or  sacculated  aneurism  and  a  dilated  aorta.  I  did  not 
elicit  any  increased  dulness  over  the  dilatation,  probably  because  in 
percussing,  I  failed  to  place  the  patient  in  the  position  with  the  chest 
bent  downwards.  There  were  no  mitral  murmurs,  but  the  evidences 
of  aortic  stenosis  and  insufficiency  were  recognized,  as  is  seen  by 
my  notes,  and  they  are  confirmed  by  my  colleague.  Prof.  S.  S.  Burt. 
A  feature  of  the  case,  however,  was  paroxysms  of  the  infrequent 
pulse,  which  varied  from  48  to  58  during  a  great  part  of  the  three 
years  and  more  he  was  under  my  care.  In  the  summer  of  1903 
he  passed  from  under  my  observation,  and  I  have  no  subsequent 
notes  of  his  case.     He  died  in  the  December  following. 

Percussion  may  be  made  directly  on  the  sternum,  and  if  the 
breadth  is  found  to  be  greater  than  the  normal  we  have  dilatation. 
If  there  is  pericarditis  it  may  involve  the  pericardium,  and  we  may 
have  the  signs  of  dry  pericarditis.  Pressure  on  the  brachial  plexus 
may  also  cause  atrophy  of  the  corresponding  limb,  or  d3"sphagia  may 
result  from  pressure  on  the  oesophagus.  Again,  it  is  said,  the  pouch 
of  the  aorta  may  press  forward  and  cause  pulsation,  seen  and  felt 
through  the  skin  in  the  second  right  space. 

A  most  noteworthv  sig-n  is  aortic  insufficiencv,  and  with  it  the 


2y2  Aortitis 

"long  heart,"'  two  conditiotis  that  are  very  apt  to  be  associated  with 
chronic  aortitis. 

Gueneau  de  Alussy--  thinks  that  an  important  sign  is  a  second 
cardiac  sound  heard  over  the  course  of  the  vessels,  and  metallic  or 
clanging  in  character,  the  "chant  du  crapaud"  or  "bruit  tynipan- 
u]uc,"  so-called  from  its  resemblance  to  the  croaking  of  a  frog  or 
the  clanging  of  a  drum.  According  to  Paul  {Dis.  of  the  Heart, 
N.  Y.,  1884)  the  signs  of  Hodgson's  Disease  are: 

Dyspnoea  on  etitort ;  vertigo  due  to  cerebral  anjema ;  hard 
radials ;  sinuous  arteries.  As  the  aorta  does  not  extend  beyond 
the  sternum  in  health,  and  is  15  to  20  centimeters  below  the  episternal 
notch,  if  the  dulness  extends  beyond  these  points  we  have  dilatation. 
Bruit  in  aorta  and  large  vessels,  and  over  surrounding  organs.  Un- 
equal pulse  due  to  obstructive  changes  in  vessels.  Dulness  over 
upper  part  of  the  sternum  and  right  lung. 

The  bruit  may  be  as  much  as  4  centimeters  from  the  right  border 
of  the  sternum.  The  aorta  may  be  perceptible  above  the  aortic 
notch.  The  bruit,  which  lasts  through  the  entire  ventricular  systole, 
may  be  double  when  there  is  a  sharp  projecting  plate,  which  gives 
a  murmur  both  in  systole  and  when  the  blood  flows  back  to  close 
the  semilunar  valves.  As  the  roughness  in  the  aorta  increases,  there , 
is  more  harshness  in  the  murmurs.  The  heart  now  hypertrophies, 
and  the  apex  may  be  in  the  sixth  left  space.  There  may  be  compres- 
sion of  the  trachea. 

Laboulbene  {Anat.  Path.,  Paris,  1879,  p.  640)  gives  an  additional 
sign  of  Hodgson's  Disease,  namely,  the  projection  upwards  of  the 
subclavian  as  a  means  of  determining  the  dilatation  of  the  aorta. 

Sansom  (Tzuentieth  Century  Med.,  Vol.  IV.)  gives  the  following 
signs :  Difficulty  of  breathing  with  a  sense  of  weight  or  constric- 
tion of  the  chest,  the  peculiar  respiration  being  that  of  a  long  and 
painful  inspiration  with  a  short  expiration.  Orthopnoea.  Pain  of 
a  severe  character  in  the  mid-sternum,  or  radiating  to  the  neck 
and  down  the  right  arm.  (Albutt^^  finds  this  pain  may  be  absent, 
and  he  refers  it  to  the  root  of  the  aorta.)  Other  signs  given  are 
insomnia,  coldness  of  the  extremities,  vertigo,  dyspepsia.  Angina 
pectoris  is  apt  to  be  associated. 

If  there  is  decided  prsecordial  pain,  the  patient  should  rest  in 
bed,  while  cold  applications  may  be  made  to  the  chest.  Chloralamid 
in  20  to  30-grain  doses  may  be  given  to  promote  sleep,  perhaps  an 


''  Gueneau,  de  Mussy,  Clinique  Medicate,  Vol.  IV,  p.  470  et  seq. 
Albutt,  Lancet,  July  18,  1903. 


Aortitis  273 

opiate  for  a  similar  reason,  or  to  relieve  pain.  The  treatment  in 
general  is  that  of  arteriosclerosis. 

Simple  dilatation  of  the  aorta,  independently  of  disease  of  the 
coats,  may  occur  as  a  result  of  obstruction  of  the  vessel  in  advance 
of  the  dilatation,  or  of  violent  cardiac  action,  and  is  common,  accord- 
ing to  Quincke,  among  men  whose  work  consists  of  violent  mus- 
cular effort,  such  as  stokers  and  sledgers.  It  is  due  to  the  resistance 
offered  to  the  systemic  circulation  by  muscular  contraction ;  and 
also  to  the  backward  pressure  in  the  distended  veins. 

There  is  only  one  place  where  the  dilatation  of  the  aorta  can  be 
felt  by  the  fingers,  and  that  is  in  its  abdominal  portion,  where  it 
may  also  be  seen. 

Such  dilatations  may  be  permanent,  but  more  commonly  are  of  a 
temporary  character,  and  due  to  paresis  or  paralysis  of  the  vaso- 
constrictors. 


Chapter  XXI\' 


ARTERIOSCLEROSIS. 


The  lucaniug  of  the  word  arteriosclerosis,  originally  applied  to 
proliferative  ami  degenerative  changes  in  the  aorta  and  larger 
vessels,  has  been  gradually  expanded  in  accordance  with  our  increas- 
ing knowledge,  so  that  now.  while  it  is  strictly  limited,  ctyniologi- 
cally  speaking,  to  changes  in  the  arteries,  it  is  intended  to  be  de- 
scriptive of  systemic  processes  that  embrace  not  only  arteries, 
capillaries,  and  veins,  but  lymphatics  also.  IMainly,  then,  Tlioma 
was  correct  in  contending  that  arteriosclerosis  is  no  longer  adequate 
to  express  this  condition  of  the  vessels,  which  is  more  properlv  an 
angiosclerosis,  if  we  look  at  the  subject  from  the  broad  point  of  view 
taken  by  pathologists.  At  the  same  time,  there  is  no  reason  to 
abandon  the  word  arteriosclerosis,  because  both  from  a  pathological 
and  clinical  point  of  view,  the  changes  in  the  arteries  are  the  most 
conspicuous  incidents  of  the  affection.  To  be  sure,  it  may  not  have 
been  demonstrated  that  angiosclerosis  can  affect  everv  organ  and 
tissue  of  the  body,  but  it  is  certainly  true  of  the  capillaries  and  small 
arteries  of  the  pia.  retina,  kidneys,  heart,  lungs,  spleen,  stomach, 
brain  and  spinal  cord,  so  that  it  is  probable  that  no  organ,  tissue 
or  vessel  escapes.  In  the  capillaries  and  smaller  vessels,  where  the 
disease  appears  to  originate,  the  changes  consist  of  infiltration,  fatty, 
calcareous  and  hyaline  changes,  with  pigmentation,  followed  by  dila- 
tation, then  contraction,  perhaps  embolism,  thrombosis,  or  even 
rupture.  These  changes  are  less  conspicuous  in  the  veins,  though 
they,  too,  undergo  hypertrophy,  atrophy  and  degenerative  alteration, 
certainly  in  such  systemic  diseases  as  gout,  syphilis  and  tuber- 
culosis ;  and  all  vessels  are  in  a  measure  similarly  though  not  equally 
affected.  In  syphilis  and  gout,  however,  the  arteries  suffer  most 
from  the  poison.  So  far  as  the  larger  arteries  are  concerned,  the 
following  anatomical  facts  should  be  borne  in  mind.  A  layer  of 
flattened  endothelium  cells  lines  the  vessels.  External  to  them  is  the 
tunica  intima,  or  true  internal  coat,  composed  of  networks  of  elastic 
tissue  arranged  longitudinally.  These  two  coats  go  to  make  up  the 
internal  coat  of  the  older  writers.  More  externally,  the  middle  coat 
is  made  up  of  muscular  fibres  arranged  transversely,  together  with 
elastic  fibres.  Still  more  external  is  the  outer  coat,  made  up  of  con- 
nective tissues. 


Arteriosclerosis  275 

In  arteriosclerosis,  using  the  term  in  its  restricted  sense,  as  ap- 
plied to  arteries  only,  and  as  the  condition  is  seen  by  the  naked  eye, 
there  are  three  stages  into  which  it  can  be  conveniently  divided. 
Exposing  the  interior  of  the  vessel,  the  inner  surface  is  marked 
here  and  there,  in  a  somewhat  irregular  way,  by  greyish-white  or 
pellucid  patches,  which  appear  to  be  actually  adherent  to  the  lining 
membrane.  As  a  matter  of  fact,  they  lie  between  the  tunica  intima 
and  media.  This  is  the  first  stage.  The  material  of  which  the  de- 
posit is  made  up  is  a  firm  but  elastic  substance,  the  result  of  inflam- 
mation, and  developed  from  the  deeper  cells  of  the  tunica  intima. 
The  condition  is  therefore  an  endarteritis,  and  Virchow's  conten- 
tion, that  it  is  developed  from  the  tunica  intmia,  is  correct.  I>ut  this 
newly  formed  tissue  is  not  destined  to  produce  healthy  tissue  in 
every  instance.  Like  all  the  results  of  inflammatory  action,  it  is 
deficient  in  vitality,  and  is  soon  apt  to  fall  a  prey  to  fatty  change ; 
so  that  the  original  whitish  or  pellucid  substance  may  become  yellow, 
and  its  consistence  pasty.  In  other  words,  we  have  atheroma — the 
second  stage.  Now,  this  atheromatous  process  once  started  may 
continue  to  extend.  At  first  the  endothelial  coat  resists,  while  the 
internal  coat  ofl^ers  less  resistance ;  but  in  the  end  the  former  gives 
way,  leaving  the  inner  surface  of  the  vessel  rough  and  worm-eaten 
in  appearance — the  atheromatous  ulcer. 

On  the  other  hand,  while  the  patch  may  disintegrate,  it  may 
not  discharge  its  contents  into  the  vessels,  but  may  simply  dry  up 
and  calcify.  This  is  the  third  stage.  The  appearances  are  now  dis- 
tinctive. If  in  the  aorta,  plates  or  spicula  of  bony  hardness,  possibly 
an  inch  or  more  in  length,  may  project  into  the  lumen  of  the  vessel. 
In  the  larger  arteries  these  plates  may  take  the  form  of  bands  encir- 
cling the  vessels.  Arteriosclerosis  in  the  second  and  third  stages 
is  quite  common  in  the  aorta.  Indeed,  after  middle  life  there  is 
usually  more  or  less  of  atheroma  or  calcareous  substance  in  it,  and 
at  this  period  each  of  the  three  stages  can  often  be  seen  in  the 
aorta  of  a  single  person ;  the  pearly  deposits  of  the  first  and  the 
bright  yellow  of  the  fatty  and  calcareous  deposits  of  the  second  and 
third  stages  being  outlined  against  the  reddened  tissue  of  the  normal 
portion  of  the  vessel.  In  syphilitics  this  process  may  be  seen  in 
young  persons  who  have  not  undergone  appropriate  treatment. 
Sclerosis,  however,  is  not  evenly  distributed  in  the  arteries,  so  that 
the  discovery  of  stifif  radials  does  not  imply  a  similar  condition  in 
every  vessel  of  the  body.  There  appears  to  be  some  determining 
cause  that  relegates  the  disease  to  a  special  part,  and  in  point  of 


276  Arteriosclerosis 

frequency,  so  far  as  our  present  inforniation  goes,  we  may  safely  say 
that  the  distribution  is  about  in  the  order  following :  first,  in  the 
aorta,  then  in  the  cerebral  vessels,  coronaries.  and  rLiial  vessels,  and 
finally  in  arteries  of  the  extremities. 

There  are  various  dangers  to  which  the  arteriosclerotic  individual 
is  exposed.  Owing  to  the  retardation  of  the  blood  current  by  ob- 
struction, and  the  loss  of  elasticity  in  the  vessels,  there  will  be  failure 
in  the  nutrition  of  the  various  parts.  In  the  brain  this  may  cause 
cerebral  softening,  independently  of  embolism  or  thrombosis.  Where 
there  is  an  atheromatous  ulcer  in  a  vessel,  the  blood  may  penetrate 
between  the  coats  and  cause  a  dissecting  aneurism,  or  the  yielding 
of  the  external  coat  may  cause  a  saccular  aneurism.  Sometimes  the 
vessel  bursts ;  this  is  liable  to  occur  in  cerebral  vessels  that  have  very 
thin  walls.  Occasionally  a  diseased  coronary  bursts  ;  or  an  artery 
may  be  more  or  less  completely  blocked  by  fibrine  lodged  on  a  cal- 
careous spicule  or  a  roughened  surface.  This  may  cause  senile 
gangrene,  and  it  is  observed  in  the  extremities.  Embolism  in  dis- 
tant parts  is  also  another  incident.  Owing  to  the  rigidity  of  the 
arteries,  the  left  ventricle  is  forced  to  hypertrophy  in  order  to  do 
more  work.  Dropsical  effusions  are  also  common,  not  so  much 
from  the  dilated  arteries  as  from  the  dilated  veins,  capillaries  and 
lymphatics. 

In  the  capillaries  the  disease  appears  to  begin  with  some  altera- 
tion in  tlie  contents  of  the  endothelial  cells  about  the  nuclei ;  the 
whole  body  of  the  cell  being  infiltrated,  subsequently,  so  as  to  be- 
come turbid  in  appearance.  In  the  arteries  the  several  coats  are 
successively  invaded,  until  the  walls  of  the  vessels  become  infiltrated 
with  a  material  that  is  at  first  fibroid,  later  fatty,  and  finally  cal- 
careous, if  the  process  proceeds  sufficiently  far.  As  for  the  veins,  it 
is  probable  that  the  disease  commences  in  the  same  way — from  the 
endothelium  of  the  inner  coats.  Those  who  maintain  this  theory 
believe  that  the  special  irritation  causing  the  inflammation  is  due 
to  poisonous  bacteria,  or  their  toxins,  coursing  in  the  blood  ;  or,  as  in 
lead  poisoning,  to  the  absorption  of  metallic  substances.  But  others 
believe  that  the  poisons  are  absorbed  by  the  vaso-vasorum  of  the 
vessels,  and  penetrate  from  without  inwards.  This  latter  explana- 
tion w^ould  hold  good  for  arteries  and  veins  only,  and  not  for  the 
capillaries,  for  they  have  no  vaso-vasorum.  On  the  whole,  if  we 
are  to  accept  a  single  theory,  the  former  harmonizes  best  with  known 
facts. 

Arteriosclerosis  is  also  a  senile  change,  due,  perhaps,  to  paralysis 


Arteriosclerosis  zyj 

or  atony  of  the  muscular  coats  of  the  vessels.  There  are  two 
forms  of  arteriosclerosis,  the  nodular  and  the  ditlfuse.  The  nodular 
chiefly  affects  the  larger  vessels  of  the  body  and  extremities  and 
those  at  the  base  of  the  brain.  In  this  form  the  process,  microscopi- 
cally speaking,  seems  to  be  as  follows :  The  deeper  layers  of  the  in- 
tima  are  thickened  by  the  irritation  of  bacteria,  or  by  the  morbid  con- 
stituents of  the  flowing  blood.  These  poisons  cause  proliferation  of 
the  cells,  which  eventually  develop  into  fibroid  tissue.  Later  the 
muscle  cells  become  swollen  and  undergo  hyaline  change.  Eventu- 
ally the  adventitia,  or  external  coat,  is  so  involved  that,  as  already 
said,  there  gets  to  be  general  infiltration  of  the  entire  vessel.  In  the 
diffuse  form  the  change  is  more  uniformly  distributed.  Both  intima 
and  media  undergo  the  same  hyaline  change,  while  the  elastic  coat 
disappears.  When  the  smaller  arteries  are  involved,  their  lumens 
are  apt  to  become  contracted  ;  though  infiltration  of  a  vessel  may 
take  place  without  appreciable  narrowing  of  the  lumen.  However, 
in  a  certain  number  of  cases  the  contraction  may  be  so  great 
as  to  lead  to  obstruction,  partial  or  complete,  and  so  to  thrombosis 
and  embolism.  Occasionally  an  artery  may  be  entirely  obliterated 
by  this  process  of  infiltration  and  contraction — obliterating  arteritis. 

A  probable  chain  of  events,  so  far  as  the  heart  and  arteries  are 
concerned,  appears  to  be:  first,  an  increased  tension  of  the  arteries, 
due  to  obstruction  in  the  capillaries,  followed  by  a  loss  of  elasticity 
in  the  arteries  and  slowing  of  the  blood  stream,  so  that  the  vessels 
no  longer  aid  in  propelling  the  blood.  Influenced  by  these  condi- 
tions, the  left  ventricle  becomes  hypertrophied,  and  later  dilated. 
Increased  tension,  however,  leads  to  infiltration,  and  this  in  turn  to 
degenerative  changes,  by  which  in  the  final  stage  the  artery  may 
be  converted  into  a  rigid  tube.  To  a  certain  extent  the  infiltration 
of  the  walls  of  the  vessels  is  a  compensatory  process,  for  by  it  the 
dilated  vessels  are  strengthened ;  but  fortunately  this  new  tissue  is 
apt  to  suffer  from  innutrition,  and  degenerates  in  consequence,  so 
that  an  aneurism  will  form,  or  even  rupture  may  take  place.  In 
syphilis  we  see  examples  of  the  one,  and  in  senile  change,  of  the 
other.  On  the  other  hand,  the  new  tissue  may  become  tolerably  well 
organized,  and,  contracting,  aid  in  restoring  a  dilated  vessel,  more  or 
less,  to  its  former  size.  Unfortunately,  the  beneficial  results  of  the 
cicatrical  contractions  are  apt  to  be  few,  and  the  degenerative  changes 
many,  so  that  the  vessel  is  unevenly  distended. 

In  some  cases,  the  heart  is  not  found  hypertrophied  ;  it  has  then 
probably  been  at  some  time  hypertrophied,  but  has  afterwards  con- 


2/8  Arteriosclerosis 

r 

tracted.  Tliis  wuuUl  explain,  in  i)art.  why  the  senile  heart  in  arterio- 
sclerosis is  sometimes  small.  Another  cause  of  contraction  may 
lie  in  the  shrinking  of  the  heart  walls  from  the  fibroid  changes.  But 
the  disease  extends  beyond  the  vessels,  for  in  every  organ  affected 
the  parenchyma  is  sure  to  suflfer,  because  its  nutrition  is  affected. 
In  the  brain,  as  \vc  have  seen,  there  may  be  softening;  in  the  kid- 
neys, contraction ;  in  the  heart,  atrophy  or  degeneration  of  the 
muscle  fibres,  with  interstitial  fibroid  deposits  originating  in  the 
siieaths  of  the  vessels  and  penetrating  between  the  muscle  bundles. 
When  the  pulmonary  or  bronchial  arteries  are  affected,  the  lung 
parenchyma  also  suffers.  There  are  other  conditions,  nainely,  acute 
aortitis  and  acute  arteritis,  which  should  be  alluded  to  here,  because 
they  have  a  bearing  on  the  chronic  disease.  There  is  no  doubt  that 
acute  aorititis  exists,  and  its  occurrence  has  been  associated  with  a 
sense  of  oppression  or  substernal  pain,  dyspnoea,  some  irregularity 
of  the  pulse,  and  fever.  But  we  have  not  yet,  I  think,  reached  the 
point  where  it  can  be  differentiated  from  acute  endocarditis. 

Acute  arteritis,  however,  oft'ers  less  difficulties.  It  may  occur 
in  acute  or  chronic  infective  diseases,  such  as  typhoid  and  influenza, 
acute  rheumatism  and  diphtheria.  It  appears  to  elect  by  preference 
the  arteries  of  the  lower  limbs.  In  fact,  the  theory  that  inflammation 
of  the  smaller  arteries  plays  an  important  role  in  the  causation  of 
the  exanthems  of  eruptive  fevers,  due  possibly  to  the  toxins  of  the 
causative  bacteria,  is  plausible.  In  diseases  where  the  strain  falls 
on  the  left  heart,  the  left  ventricle  is  more  prone  to  this  connective 
tissue  infiltration  and  muscular  degeneration  ;  but  where  the  burden 
falls  on  the  right  heart,  the  right  ventricle  is  most  often  affected, 
as  in  tubercular  and  syphilitic  phthisis.  The  occurrence  of  haemor- 
rhage in  arteriosclerosis  is  thus  explained. 

The  greatest  pressure  on  the  arterial  wall  is  just  in  front  of  the 
thickened  part.  Here  it  begins  to  yield,  little  by  little,  becoming 
thinned  and  stretched  and  finally  somewhat  sacculated.  When  the 
sac  gives  way.  hemorrhage  takes  place.  In  arteriosclerosis  there  is 
an  increased  tension  in  the  vessels.  The  radial  pulse  is  hard  and 
firm  ;  in  advanced  cases,  rigid.  The  heart  is  usually  hypertrophied, 
though  in  senile  cases  it  may  be  of  normal  size  or  even  atrophied, 
owing  to  causes  that  have  been  described.  The  heart  usually  beats 
with  vehemence.  Stiffness  and  tortuosity  of  the  radials  is  another 
important  sign.  In  determining  the  character  of  the  peripheral 
arteries,  the  pulse  especially,  three  fingers  are  useful.  If.  when 
moderate  pressure  is  made  with  the  finger  nearest  the  heart,  you  can 


Arteriosclerosis  279 

still  feci  the  pulse  beat  with  the  other  fingers,  there  is  a  moderate 
amount  of  arteriosclerosis.  If  by  moderate  pressure  you  do  not 
affect  the  pulse  beat  on  the  distal  side,  there  is  great  arteriosclerosis. 
Other  symptoms  are  vague  tingling  or  numbness,  especially  in  the 
left  arm  and  fmgers  when  these  parts  are  at  rest,  and  coldness 
of  the  limbs  and  feet.  The  muscles  are  soft  and  there  is  a  tendency 
to  corpulency.  The  pulse  is  also  apt  to  be  less  frequent  than  normal. 
Precordial  pain  is  often  developed  by  exercise  or  unusual  exertion. 
After  middle  life  a  ringing  second  sound  over  the  aorta  is  thought 
to  indicate  arteriosclerosis ;  if  coupled  with  high  arterial 
tension  it  may  be  regarded  as  pretty  good  evidence  of  coronary 
sclerosis.  Angina  pectoris  has  been  held  to  indicate  implication  of 
the  coronaries ;  but  the  connection  is  not  constant.  In  fact,  angina 
is  rather  rare  in  coronary  sclerosis  ;  and  yet  coronary  sclerosis  is 
very  common  in  angina. 

Among  other  prominent  signs  that  have  been  thought  worthy 
of  note  is  the  sallow,  pale  face ;  its  color,  however,  may  be  red  from 
the  abnormal  development  of  the  arterioles,  the  fades  arteriosclero- 
tica.  Sometimes  pecular  wreaths  or  festoons  formed  of  dilated 
venous  radicles  are  seen  as  a  girdle  about  the  lower  part  of  the  chest. 
I  have  several  such  cases  under  my  observation  now,  but  they  are 
not  pathognomonic  of  ordinary  arteriosclerosis ;  at  least  they  are  to 
be  seen  sometimes  in  the  phthisis  of  young  people. 

If  the  heart  gives  way,  the  pulse  will  become  weak,  intermittent 
or  deficient ;  attacks  of  gastralgia  may  occur  with  or  without  angina, 
with  palpitation  and  cardiac  asthma.  Sometimes  there  will  be  verti- 
go, or  the  Adams-Stokes  syndrome. 

There  are  various  types  of  the  disease.     In  the  first  place  there 
is  the  cardiovascular,  such  as  is  seen  in  the  gangrene  of  the  extremi- 
ties in  diabetics  and  in  senility. 
The  following  case  is  illustrative : 

Case  XCVI.  Gangrene  of  Feet;  Arteriosclerosis,  Aortic  and 
Mitral  Endocarditis. — Some  years  ago  I  made  a  post-mortem  exam- 
ination in  the  practice  of  one  of  our  late  surgeons.  An  abstract 
of  the  case  is  as  follows :  A  gentleman,  49  years  of  age,  was  seen  in 
consultation  on  August  15,  1877.  Some  20  years  previously  there 
had  been  a  rheumatic  attack  and  subsequently  others,  attended  with 
cardiac  symptoms.  In  the  previous  spring  the  patient,  while  in 
bed,  became  suddenly  unconscious  and  remained  so  for  three  hours. 
In  the  latter  part  of  June  he  began  to  suft'er  from  pain  in  the  lower 
extremities,  chiefly  in  the  calves,  and  particularly  in  that  of  the  left 


28o  Arteriosclerosis 

leg.  A  week  before,  he  first  noticed  a  violet  discoloration  in  the 
fourth  toe  of  the  left  foot.  When  examined  by  the  attending  physi- 
cian, no  pulsation  was  found  in  the  femorals  below  Scarpa's  space. 
Four  days  after  the  beginning  of  the  gangrene  in  the  left  foot,  a 
similar  process,  in  a  similar  place,  appeared  on  the  right  foot.  No 
cardiac  murmurs  were  detected.  If  present,  it  was  thought  they  had 
been  masked  by  the  feeble  action  of  the  heart.  The  question  of  am- 
putation was  entertained,  but  this  procedure  was  not  advised.  The 
patient  lingered  several  months,  to  die  with  symptoms  of  pneumonia. 
At  the  post-mortem  examination  the  b.eart  was  found  large,  lioth 
ventricles  were  dilated,  the  left  considerably  hypertrophicd.  Aortic 
orifice  contracted  and  calcified,  also  the  mitral  (button  liole  open- 
ing.) In  the  upper  lobe  of  the  left  lung  there  were  hccmorrhagic 
infarctions  of  various  sizes,  with  surrounding  pneumonia.  Kidneys 
also  contained  infarctions;  surfaces  granular;  Spleen  small,  con- 
tracted and  containing  calcific  deposits  and  cicatrices.  Abdominal 
aorta  marked  by  atheromatous  patches  throughout  its  whole  extent. 
The  right  common  iliac  thickened  by  calcific  deposits  and  at  points 
ulcerated.  Occlusion  of  the  left  femoral  just  below  the  point  where 
the  profunda  was  given  off.  From  this  point  downward  the  vessel 
was  filled  with  a  firm  plug.  In  the  right  femoral  the  plugging  oc- 
curred in  the  lower  part  of  the  vessel,  just  above  the  popliteal. 

In  another  case  (Case  XCVII),  occurring  in  the  hospital  prac- 
tice of  the  late  Dr.  Alfred  C.  Post,  where  gangrene  had  involved 
nearly  all  of  the  left  hand,  the  patient  was  a  man  58  years  of  age, 
who  entered  the  hospital  sufifering  from  great  debility,  emaciation, 
nausea  and  vomiting.  At  the  post-mortem  examination  all  the 
arteries  of  one  extremity  were  found  to  be  thickened  and  athero- 
matous, the  radial  being  occluded  by  a  thrombus.  In  these  instances 
of  arteriosclerosis  in  peripheral  arteries,  there  are  apt.  of  course,  to 
be  associated,  as  in  Case  XCVI,  symptoms  of  vascular  disease  in 
other  parts.  But  there  may  be  also  the  purely  gastrointestinal  type, 
due  to  interference  with  the  circulation  and  leading  to  congestion  of 
internal  viscera,  as  indicated  by  signs  of  acute  or  chronic  dysj^epsia, 
marked  gastralgia  and  flatulency,  perhaps  nausea  and  vomiting.  On 
the  other  hand,  these  same  symptoms  may  be  due  to  interstitial 
thickening  of  the  chylopoetic  viscera.  The  glycosuria  so  common 
in  aged  arteriosclerotics,  however,  may  be  explained  by  the  sclerotic 
condition  of  the  pancreatic  arteries.  On  the  other  hand,  there  may 
be  localized  ischsemia  of  the  stomach,  causing  functional  inadequacy. 

The  theorv  that  many  gastric  or  duodenal  ulcers  are  due  to  cir- 


Arteriosclerosis  281 

culatory  disturbances  is  based  on  soiincl  tbeoretical  principles,  in  so 
far  as  such  disturlmnces  are  competent  to  produce  embolism,  throm- 
bosis, or  even  ha^morrhag-e,  anywhere  in  the  body  ;  but  as  a  matter 
of  fact,  it  does  not  ajipear  that  the  stomach  or  intestines  suffer 
much  from  this  cotuhtion  of  the  circulation,  probably  on  account 
•of  their  excellent  collateral  circulation.  Still  Berthold,'  of  lierlin, 
has  reported  that  of  two  hundred  and  ninety-four  cases  of  gastric 
ulcer,  in  one  hundred  and  seventy  (or  58  per  cent.),  there  were 
disorders  of  circulation,  chiefly  endocarditis  and  atheroma,  and 
Steiner-  found  an  even  larger  percentage  (71  out  of  no,  or  about 
64  per  cent.). 

The  following  is  an  illustrative  instance  of  this  type: 

Case  XCVIII.  Gastric  Ulcer;  Arteriosclerosis.— Mrs.  D.,  67, 
English,  an  alcoholic  subject,  was  first  seen  by  her  physician  Septem- 
ber I,  1883.  She  then  complained  of  pain  in  the  right  side,  loss  of 
strength,  sleeplessness  and  gastric  distress,  associated  with  acid  eruc- 
tations and  vomiting.  Constipation  and  colicky  pains,  with  move- 
ments that  were  at  times  dark,  and  even  black  and  offensive.  The 
patient  had  been  dropsical  for  years  and  had  suffered  from  asthma. 
Weight,  about  200  lbs. 

On  examination  there  was  found  a  diffuse  heart  beat,  no  mur- 
murs, but  sounds  muffled.  Heart's  action  irregular.  Pulse  80-100. 
Small,  rigid  radials.  Indications  of  pneumonia  and  cirrhosis.  Gen- 
eral oedema.  Urine  scanty,  high  colored  and  albuminous.  Patient 
peevish,  with  signs  of  hebetude,  but  no  special  brain  symptoms.  She 
■died  in  coma.  At  the  post-mortem  examination  the  heart  was  found 
enlarged  and  the  aorta  dilated,  but  the  valves  were  free.  In  the 
lower  lobes  of  both  lungs  small  areas  of  pneumonia.  Kidney  granu- 
lar. Liver  cirrhotic.  The  stomach  contained  a  small  ulcer,  but  it 
was  thought  to  be  so  insignificant,  that  it  could  have  given  no  signs. 
Its  cause,  however,  may  have  been  the  rupture  of  a  minute  artery  in 
the  organ. 

The  following  case  of  arteriosclerosis  is  interesting  because  the 
cause  of  death,  while  ascribed  to  some  affection  of  the  stomach  or 
■duodenum,  is  still  obscure. 

Case  XCIX.  Hcemorrhage,  Probably  from  Duodenal  Ulcers  Due 
to  syphilitic  arterisclcrosis. — A  laborer,  between  40  and  50.  had  been 
complaining  of  a  pain  in  the  cardiac  end  of  the  stomach  for  several 
weeks  before  admission  to  the  hospital.    While  at  his  work,  in  which 


^Berthold  quoted  by  Welch,  Amcr.  System  of  Med..  Vol.  TI. 
^  Steiner,    Pepper's  System,  Vol.  II,  p.  487. 


282  Arteriosclerosis 

he  was  not  exposed  to  special  strain.  Ik  lK\L;an  brin^in^-  np  blood 
by  the  mouth  and  later  passed  it  per  anuni.  lie  ilied  a  few  hours 
after  admission,  with  all  the  siij^ns  of  internal  hemorrhaj^e.  At  the 
post-mortem  examination  there  were  found  clearlv  marked  copper- 
colored  spots  on  the  left  Ic"'.  Left  heart  atro])hied.  All  valves  free 
and  sufficient.  In  the  aorta,  atheromatous  patches  and  calcareous 
plates.  Aortic  arch  dilated  throu.^hout.  At  the  junction  of  the 
first  and  second  portions  of  the  arch  on  the  convex  side,  a  small 
sacculated  aneurism.  Tn  the  remaining  portions  of  the  artery,  en- 
darteritis. Colon  and  lower  ])ortions  of  small  intestines  filled  with 
blood.  Tn  the  stomach,  which  contained  blood,  the  rugae  were 
prominent  and  deeply  stained  with  blood.  No  ulceration  of  the 
stomach,  but  in  the  duodenum,  just  below  the  pylorus,  were  several 
suspicious-looking  spots  in  the  mucous  membrane,  with  apparent 
loss  of  substance,  possibly  from  the  rupture  of  miliary  aneurisms. 
The  liver  was  larger  than  normal,  but  not  cirrhotic.  The  evidences 
therefore  pointed  to  death  caused  by  minute  ulcers  of  the  duodenum, 
due  to  syphilitic  arteriosclerosis. 

Tn  chronic  renal  disease  wath  induration,  there  is  an  early  dis- 
turbance of  renal  functions,  though  the  urine  at  first  shows  nothing 
pathological.  There  are  then  no  positive  subjective  symptoms.  But 
w'hen  there  is  a  low  specific  gravity  and  an  occasional  trace  of  al- 
bumin with  casts,  renal  sclerosis  is  at  hand.  In  fact,  a  diagnosis 
based  on  these  points  is  apt  to  be  correct ;  especially  if  there  are 
hyaline  casts  with  the  granular,  and  the  amount  of  urine  is  ab- 
normally large.  Even  here,  however,  there  is  often  a  general  hyper- 
trophy of  the  cardio-vascular  system  more  or  less  pronounced,  from 
the  one  extremity  to  the  other.  The  following  is  an  illustrative 
case: 

Case  C.  Lead  Poisoning ;  General  .h'teriosclerosis.—'K,  a  male, 
painter,  aged  79,  was  treated  by  his  physician  before  admission  to 
the  hospital  for  wrist-drop  from  chronic  lead  poisoning,  and  weak 
heart.  Under  the  use  of  the  iodide  of  potassium  he  partially  re- 
covered the  use  of  his  hand.  Shortly  before  admission,  while  at 
W'Ork.  he  had  an  attack  of  aphasia,  became  unconscious,  developed 
mania,  and  later  had  a  right  hemiplegia,  which  lasted  until  death. 
.  At  the  autopsy,  February  6,  1885,  the  heart  was  found  enlarged,  but 
the  valves  were  free.  The  aorta,  however,  was  a  mass  of  athero- 
matous patches.  In  the  muscular  tissue  of  the  heart  the  striations 
were  indistinct,  and  showed  evidence  of  brown  pigmentation.  A 
diagnosis  of  brown  atrophy  was  made. 


Arteriosclerosis  283 

Kidneys  small  and  contained  cysts.  Surfaces  j^ranular.  Liver 
an  example  of  red  atrophy.  Dura  mater  thick  and  adherent.  These 
changes  may  be  taken  to  have  implied  vascular  thickening. 

The  following  is  a  more  marked  instance: 

Case  CI.  Arteriocapillary  Fibrosis  of  Kidney;  Uraemia. — A 
patient  of  67  was  attacked  with  continuous  nausea,  vomiting  and 
some  dyspnoea.  Varying  quantities  of  a  pale  urine.  Sp.  gr.  loio 
to  1018.  Albumin  2  to  20  per  cent.  All  kinds  of  casts  present. 
Obstinate  constipaition.  Slight  muscular  twitchings,  relieved  by 
morphia.  Pupils  contracted.  Patient  died  semi-comatose.  At  the 
post-mortem  examination  the  heart  was  found  hypertrophied,  the 
liver  fatty  and  pigmented.  Aorta  dilated  and  thinned.  In  lungs 
fibroid  induration.  Spleen  hard  and  indurated.  Chronic  diffuse 
nephritis  (the  small  contracted  kidney).  The  left  kidney  weighed 
only  three,  and  the  right  four  ounces.  Stomach  small  and  con- 
tracted. Fibroid  induration  of  the  pylorus,  and  a  constriction  about 
a  foot  above  the  sigmoid  flexure.  In  this  case,  where  the  clinical 
symptoms  indicated  an  arterio-capillary  fibrosis  (Gull  and  Sutton), 
there  was  some  fibroid  induration  of  internal  organs,  while  the 
aorta  and  peripheral  arteries  apparently  showed  no  thickening. 
Then  there  is  the  cerebral  type,  associated  with  cerebral  anaemia, 
haemorrhages,  miliary  aneurisms,  and  softening,  as  well  exhibited  in 
the  retina  and  choroid,  with  many  psychic  disturbances,  such  as 
loss  of  memory,  or  senile  dementia,  vertigo,  pain  in  head  and  neck, 
involuntary  tremors,  and  diplopia,  with  specks  or  flashes  before 
the  eyes. 

Case  CII.  Cerebral  Hemorrhage,  Arteriosclerosis. — A  man 
84  years  of  age  w^as  found  locked  in  a  room  and  unconscious,  with 
some  right  facial  paralysis  and  right  hemiplegia.  Superficial  re- 
flexes absent  on  both  sides,  and  deep  reflexes  on  the  right  side.  Died 
of  pulmonary  oedema  a  few  hours  after  admission  to  the  hospital. 
At  the  post-mortem  examination  the  heart  was  found  but  slightly 
hypertrophied;  but  the  muscular  substance  w^as  soft,  pale  and  flabby. 
Valves  free.  In  the  aorta  some  fatty  changes,  but  no  atheroma. 
Oedema  of  both  lungs.  Kidneys  small  and  granular.  Chronic 
diffuse  nephritis.  Liver  small  and  apparently  cirrhotic.  In  the 
brain  a  clot  the  size  of  a  hen's  egg  involved  the  anterior  and  ex- 
ternal portion  of  the  lenticular  nucleus  and  external  capsule,  en- 
croaching on  the  convolutions  of  the  Island  of  Reil.  About  the  clot 
the  cerebral  substance  was  soft. 


284  Arteriosclerosis 

Liver  and  kidneys  instances  of  arteriosclerosis ;  also  a  cerebral 
hemorrhage,  due.  presumably,  to  the  bursting  of  a  miliary  anciirisDi. 

In  the  spi)ijl  t\pc,  well  exempHtied  in  the  locomotor  ataxia  of 
syhpilis,  we  have  a  disease  that  presumably  originates  in  the  vessel 
of  the  cord,  as  does  also,  probably,  the  general  paralysis  of  the  insane. 

In  the  pnUnonary  type  evidences  of  endarteritis  and  periarteritis 
have  frequently  been  found  in  the  lungs  and  bronchi  in  cases  of 
emphysema  and  spasmodic  asthma,  leading  to  the  conclusion  that 
these  vascular  changes  may  sometimes  be  due  to  gout.  Similar 
changes  are  seen  in  pulmonary  tuberculosis  and  syphilis. 

The  following  case  is  an  example  oi  arteriosclerosis  associated 
with  .syphilitic  phthisis. 

Case  cm.  Syphilitis  and  Tubercular  Arteriosclerosis.  Death 
from  Puhiionary  ITcouorrhage. — J.,  30,  stone  cutter,  of  tubercular 
ancestry,  had  suffered  from  cough  and  pain  in  the  right  side  of  the 
chest  for  six  months  before  admission  to  the  hospital.  During  this 
time  he  had  lost  15  pounds  of  flesh.  For  the  last  three  months  had 
suffered  from  dyspnoea,  and  for  the  last  four  weeks  from  night 
sweats.  He  died  of  pulmonary  hemorrhage.  At  the  post-mortem 
examination  the  heart  was  found  enlarged,  the  left  side  more  espe- 
cially. Valves  free.  At  the  apex  of  the  left  lung  was  a  large  cavity 
surounded  by  smaller  cavities,  but  the  whole  lung  was  interspersed 
with  fibroid  tissue,  separating  the  small  lobules  in  a  peculiar  man- 
ner. There  were  also  numerous  nodules  from  the  size  of  a  pin's 
head  to  that  of  a  pea.  Most  of  them  could  be  shelled  out  of  the 
capsules,  leaving  cavities  with  a  smooth  lining.  There  were  still 
other  nodules  that  looked  like  miliary  formations.  The  hemorrhage 
had  taken  place  from  one  of  the  cavities  lined  by  a  smooth  wall.  The 
lung  was  thought  to  be  the  seat  of  both  syphilis  and  tuberculosis, 
but  a  diligent  search  for  the  bacilli  of  tuberculosis  both  in  the  lung 
tissue  and  in  the  sputum,  was  unsuccessful.  The  right  lung  was  in 
a  similar  condition.  The  kidneys  were  the  seat  of  chronic  parenchy- 
matous disease.  While  no  special  examination  of  the  vessels  was 
made,  it  is  a  known  fact  that  the  vessels  in  syphilis  are  usually,  if  not 
always,  involved,  so  that  in  the  absence  of  the  bacillus  tuberculosis 
after  diligent  search  had  been  made  for  it,  the  conclusion  seemed  to 
be  justified  that  the  cause  of  death  was  internal  hemorrhage  due  to 
the  rupture  of  a  syphilitic  vessel.  Though  arteriosclerosis  is  emi- 
nently a  disease  of  advanced  life,  it  may  occur  earlier,  especially  in 
syphilis  and  in  chronic  nephritis. 

Inasmuch  as  the  longer  we  delay  treatment  in  these  cases,  the 


Arteriosclerosis  285 

less  are  the  chances  of  success,  it  behooves  us  to  make  an  early 
diagnosis  and  immediately  set  about  a  regular  plan  of  treatment. 
Of  course,  prophylaxis  aside,  we  should  endeavor  as  soon  as  possible 
to  remove  the  cause  of  the  disease,  though  this  may  not  be  alvi^ays 
possible.  Age  and  heredity  are  and  ever  will  be  the  bars  to  suc- 
cess;  and  it  may  not  be  possible  for  a  painter,  for  instance,  to  give 
up  his  profession.  But  over-indulgence  in  food  and  drink,  and  the 
"over-strenuous  life,"  can  be  combated,  while  the  danger  of  gout 
and  syphilis  can  be  minimized,  for  they  are  not  altogether  in- 
tractable. In  fact,  we  may  say  that  both  of  them,  as  well  as  tuber- 
culosis, can,  in  many  instances,  be  held  in  check. 

Apart  from  these  considerations,  the  patient  should  lead  a  quiet 
life,  free  from  its  turmoils.  And  with  good  fortune  and  little 
treatment,  an  arteriosclerotic  may  live  to  a  good  old  age.  All 
exercise  should  be  moderate,  but  at  the  same  time  a  certain  amount 
of  exercise  is  necessary.  Baths  and  resistance  exercises  are  as  use- 
ful in  the  milder  cases,  as  they  are  useless  or  dangerous  in  advanced 
cases.  If  hot  baths  cause  excitement,  as  they  are  apt  to  do  in  these 
cases,  or  resistance  exercises  cause  pain  or  any  other  untoward 
symptoms,  they  should  be  stopped  and  not  resumed.  If  there  are 
any  suspicions  of  apoplexy,  both  baths  and  resistance  exercises 
should  be  sternly  interdicted.  In  arteriosclerosis  the  medicine  that 
is  indicated  before  all  other  is  iodine.  It  should  be  used  year  in 
and  year  out,  if  we  are  to  expect  good  results.  Iodide  of  sodium, 
iodide  of  potassium  and  hydriodic  acid  may  be  followed  by  the 
/odides  of  arsenic,  iron  and  strontium,  or  free  iodine.  Iodine  ap- 
pears to  lower  the  blood-pressure  without  diminishing  the  force  of 
the  cardiac  contractions.  Aconite  is  also  useful,  and  camphor,  but 
digitalis  and  convallaria  are  harmful.  The  nitrites,  however,  are 
always  of  service.  Together  with  the  iodides,  they  are  at  present 
our  sheet  anchors. 


Chapter  XXV. 

slrgi-:rv  of  T11L-:  heart. 

Jt  has  long  been  kr.own  that  wHnnuls  of  the  heart  may  not  be 
immediately  fatal,  but  when  Fischer'  published  his  series  of  452 
cases  in  1S67  he  shewed  that  persons  could  live  for  several  days  with 
heart  wounds,  and  that  spontaneous  recovery  followed  in  from  7  to 
10  i)er  cent. 

There  are  three  classes  of  cases.  In  die  first  the  puncture  is 
very  small,  such  as  might  be  made  by  a  knitting-needle,  and  the 
muscular  tissue  about  the  wound  closes  it,  so  that  little  if  any  blood 
escapes  into  the  pericardial  cavity.  In  the  second  class,  the  wound 
does  not  reach  any  of  the  chambers  of  the  heart,  so  that  unless  the 
foreign  body  happens  to  open  a  good-sized  vessel,  the  only  result  is 
oozmg  of  a  small  amount  of  blood  into  the  pericardium.  In  the  third 
class  the  wound  is  "valvular,"  that  is,  a  chamber  of  the  heart  is 
opened,  but  by  so  oblique  an  incision  that  it  is  closed  by  every 
cardiac  contraction,  and  no  very  large  quantity  of  blood  escapes. 

It  is  only  within  the  last  ten  years  that  operations  on  the  heart 
have  been  successful. 

The  experiment  of  heart  suture  on  a  dog  by  Del  Veichio-  in 
1895  fi^st  showed  the  possibility  of  a  successful  operation  on  the  hu- 
man kind,  which  was  accomplished  by  Rehn^  in  1897.  Up  to  Oct.  i, 
1904.  acording  to  the  Lancet,  there  had  been  60  cases  of  cardiac 
suture  with  a  recovery  of  22,  or  38  per  cent.  Accordingly,  a  pre- 
ceding mortality  of  at  least  90  per  cent,  has  by  skilful  surgery  been 
converted  into  a  mortality  of  only  62  per  cent. 

According  to  the  Lancet:  "The  symptoms  of  wound  of  the  heart 
varv.  If  the  pleura  is  wounded  and  blood  escapes  into  the  pleural 
cavitv  there  are  anremia  and  the  signs  of  pneumo-haemothorax.  A 
splashing  sound  indicates  pneumo-haemopericardium ;  in  some  cases 
a  friction  sound  is  heard.  If  there  is  external  haemorrhage  the 
stream  may  be  continuous  or  in  jets.  If  the  blood  is  confined  to  the 
pericardium  the  pulse  is  very  feeble  and  death  may  result  from  pres- 
sure on  the  heart.  The  diagnosis  of  wound  of  the  heart  may  be 
difiicult  or  impossible.     The  position  of  the  external  wound  is  not 

'Fischer,  Arch.  f.  Klin.   Chir.,  Band  IX,  1867-8. 

^Del  Veichio,  Reforma  Med..  1895,  Vol.  II,  p.  38  et  seq. 

'Rehn,    Verhand.  d.  Deutsche.  Gesellschaft.  f.  Chir.,  Berlin.  1897,  XXVI. 

*  Lancet,  Oct.  i,  1904. 


Surgery  of  the  Heart  287 

a  safe  guide.  The  rule  in  (Kaibtful  cases  should  be  to  enlarge  the 
wound,  to  ascertain  if  it  penetrates  the  chest  wall,  and  if  there  be 
symptoms  of  hsemorrhage  or  of  pressure  on  the  heart  to  operate." 

In  the  history  of  a  case  of  successful  suture  of  the  heart  reported 
by  Hill"'  in  a  negro  stabbed  with  a  penknife,  the  results  in  37  cases 
were  reviewed  and  the  following  conclusions  drawn : 

The  operation  for  heart  suture  is  entitled  to  a  permanent  place 
in  surgery.  Every  heart  wound  should  be  operated  on  immediately. 
Even  if  there  is  only  a  suspicion  of  it,  an  exploratory  incision  should 
.  be  made.  Chloroform  is  the  preferable  anaesthetic.  The  wound 
should  not  be  probed.  Rotter's"  operation  renders  the  access  to  the 
heart  easy.  Steady  the  heart  before  attempting  to  suture  it,  either 
by  placing  the  hand  under  the  organ,  and  lifting  it  up  ;  if  the  hole 
is  large  enough,  introduce  the  little  finger.  Catgut  sutures  should 
be  used,  as  wounds  of  the  heart  heal  promptly.  The  sutures  should 
not  involve  the  endocardium,  should  be  interrupted  and  tied  during 
diastole.  As  few  as  possible  should  be  used.  The  pericardium 
should  be  cleansed,  but  no  fluid  poured  into  the  sac.  The  wound  of 
the  pericardium  should  be  closed.  If  symptoms  of  compression 
enstie,  reopen  the  wound  and  drain. 

In  a  bullet  wound  case  recently  reported  to  the  Paris  Society  of 
Surgery  (Tufifier,  Bull,  et  Mem.  de  la  Socicte  de  Chir,  29,  1903,  p. 
957),  where  the  radiograph  disclosed  a  foreign  body  in  the  left  wall 
of  the  heart,  and  moving  with  that  organ,  a  portion  of  the  second  left 
costal  cartilage  was  removed.  The  finger  passed  under  the  border 
of  the  lung  located  the  bullet.  The  overlying  tissue  was  then  laid 
bare  and  the  ball  extracted.    The  patient  recovered. 


"  Hill,  Me.d  Rec,  Nov.  29,  1902. 

°  Rotter,   Verhandl.   d.   Gesell.   Deutsch.   Natiirfor.   lutd  Aersfe,   1899.   II, 
541. 


APPENDIX. 

I.       CONGENITAL    HEART    AFFECTIONS. 

Malformations  of  the  heart  are  numerous.  They  may  be  serious 
or  trivial.  In  either  case  they  rarely  attract  much  clinical  interest, 
because  radical  treatment  is  impossible.  At  best  it  can  only  be 
palliative. 

Most  of  the  defects  are  due  to  arrested  development  in  the 
valves,  septa,  or  large  vessels.  Of  these  the  most  common  are  either 
patency  of  the  foramen  ovale  in  the  inter-auricular  septum,  or  im- 
proper closure  of  the  interventricular  septum.  Among  other  in- 
stances of  arrested  development  is  the  heart  with  only  one  auricle 
and  one  ventricle,  or  two  auricles  and  one  ventricle,  the  bi-locular 
and  tri-locular  hearts  respectively. 

Valvular  anomalies  are  also  comparatively  common.  The  leaflets 
may  be  more  or  less  than  the  usual  number.  In  some  cases  ante- 
natal inflammation  may  have  glued  the  segments  together,  as  in 
inflammatory  rheumatism  of  the  mother  during  pregnancy.  Among 
the  anomalies  of  the  larger  vessels,  the  aorta  and  pulmonary  may 
originate  jointly ;  or  the  aorta  may  be  displaced  to  the  right,  or  even 
arise  from  the  right  ventricle.  Then  the  ductus  anteriosus,  or  Bo- 
talli,  which  in  foetal  life  unites  the  aorta  with  the  pulmonary  artery, 
may  remain  open  after  birth. 

But  if  there  are  defects  in  the  pulmonary  artery  or  aorta,  this 
patency  of  the  ductus  arteriosus  may  be  salutary.  In  fact,  if  there 
is  a  stricture  of  the  pulmonary  orifice,  a  supply  of  blood  to  the  lungs 
through  the  ductus  arteriosus  may  be  the  means  of  maintaining  life. 
Without  doubt,  many  of  the  minor  anomalies  are  co-related  to  the 
major  forms,  one  in  one  place  compensating  for  one  or  more  in 
others.  In  some  instances,  however,  the  malformations  are  not 
sufficiently  compensated  for,  and  the  circulation  is  profoundly  dis- 
turbed. 

Others  are  of  little  consequence.  Minute  orifices  in  the  auricular 
septum  or  in  the  valves  may  evoke  no  symptoms ;  in  fact,  the  fora- 
men ovale  may  remain  partly  open,  without  deranging  the  circula- 
tion. Even  in  conspicuous  malformations,  life  may  be  maintained 
for  years. 

Of  i8i  cases  collected  by  Peacock,  119  came  in  this  category; 
155  or  86  per  cent,  living  beyond  the  12th  year. 


Appendix  289 

As  for  symptoms,  the  chief  is  cyanosis,  which  appears  within  the 
first  week  of  Hfe,  and  is  seen  in  the  fingers,  toes,  Hps  and  ears.  The 
fingers  and  toes  are  usually  clubbed.  This  condition  is  called  morbus 
caruleus  (blue  disease),  and  is  due  to  imperfect  aeration  of  the 
blood.  As  additional  symptoms  there  are  dyspnoea  and  cough,  and 
the  patients  are  lethargic. 

There  is  another  condition  called  cardiac  hypoplasia,  where  the 
heart  is  small  from  birth,  while  the  rest  of  the  body  develops  in 
proper  proportions.  Virchow  believed  that  this  condition  was 
closely  related  to  chlorosis  or  haemophilia.  The  volume  of  the 
heart  may  be  reduced  one-third.  The  arteries  of  the  aorta  are  also 
small.  After  a  time  the  increased  work  of  the  heart  may  cause 
hypertrophy.  In  some  instances  there  is  a  defective  development  of 
the  front  wall  of  the  chest.    Again,  the  pericardium  may  be  absent. 

II.      TUMORS    OF    THE    HEART. 

Tumors  of  the  heart  are  very  rare  and  are  usually  secondary.  The 
varieties  "are  sarcomas,  myomas,  myxomas,  Uhromas,  gummas,  an- 
geiomas,  lipomas,  carcinomas,  and  cysts.  Secondary  carcinoma  is 
the  most  frequent  of  all  neoplasms,  though  still  comparately  rare. 
It  has  no  preference  as  to  site.  Often  it  is  merely  an  extension  from 
a  contiguous  disease. 

Sarcomas  are  rarer  than  carcinomas.  They  occur,  however,  at 
any  age,  and  are  of  several  varieties.  Myxomas  have  been  found 
in  9  instances.  (Whittaker.)  Rarer  still  are  myomas  and  the 
remaining  four  of  the  connective  tissue  group. 

Tuberculosis  is  not  uncommon  in  the  heart ;  it  is  apt  to  involve 
the  pericardium. 

III.      ANEURISM    OF   THE   HEART. 

This  term  is  applied  to  a  partial  dilatation  of  the  heart  wall  or 
septum.  A  weak  spot  develops  in  either,  from  some  process  of 
softening  or  rupture,  and  then  the  weakened  tissue  is  "ballooned 
out."  The  clotted  blood  collected  in  the  sac  may  then  cause  sudden 
death  by  discharging  into  the  heart  cavity,  causing  embolism ;  or 
the  sac  may  burst,  causing  death  as  the  result  of  shock,  from  the 
sudden  haemorrhage. 

Syphilis  is  probably  the  most  frequent  cause  of  cardiac  aneurism, 
either  by  myocardial  softening  due  to  gummatous  tumors  or  infil- 
trations ;  or  from  the  arteriosclerosis  of  a  vessel  in  the  substance  of 
the  heart. 


290  Appendix 

There  are  no  characteristic  syniptoins.  and  it  is  not  probable  that 
a  positive  diagnosis  has  ever  been  made,  even  w  here  canHac  aneurism 
has  been  suspected.  The  iirognosis  is  unfavorable,  as  the  disease 
does  not  tend  to  self-limitation.  The  treatment  is  svmptomatic.  In 
a  case  that  came  to  m\  knowiediix.  Iioucvcr,  a  man  in  attem])tini; 
to  lift  a  heav\  weight  was  very  suddenly  taken  with  heart  failure, 
as  shown  by  his  rapid  and  irregular  pulse.  A  cure  came  w'ith  rest. 
Possibly,  and  I  think  probably,  in  this  instance  some  fibres  in  the 
wall  of  the  heart  ruptured  an  dthere  was  a  temporary  acute  aneurism, 
from  which  he  recovered  when  the  ruptured  fibres  hatl  healeil. 

I\-.        PARASITES    OF    THE    HEART. 

The  C\sticercus  and  the  Ecchinococcus  may  be  found  in  the 
heart.  They  are  comparative)}  rare,  and  are  usually  met  with  in  the 
walls  of  the  heart,  but  occasionally  involve  the  valves,  rendering 
them  incompetent,  tlydatids  vary  in  size  from  a  pin's  head  to  an 
orange.  If  the  sac  ruptures  into  a  heart  chamber,  death  may  at 
once  ensue.  This  accident  has  happened  on  several  occasions. 
Deposits  of  actinomycosis  have  also  been  found  in  the  walls  of  the 
heart.  The  diagnosis  cannot  be  made  wdth  certainty,  but  it  may 
be  suspected,  if  deposits  of  the  parasites  have  been  found  elsewhere 
in  the  body  ;  in  such  instances  embohsms  frequently  occur.  If  a 
tumor  can  be  located  in  the  walls  of  the  heart,  aspiration  may  possi- 
bly reveal  the  parasitic  character  of  the  tumor ;  or  if  a  distal  vessel 
is  plugged,  the  embolism  may  be  found  to  be  parasitic.  Surgical 
treatment  offers  the  onl\   ground  for  hope  of  life. 

v.       TREATMENT    OF    CJIROXIC    HEART    DISEASE    AT    FRAXZENSB.M). 

The  success  that  has  attended  the  management  of  heart  diseases 
in  Nauheim.  Germany,  has  led  to  the  introduction  of  the  same  line 
of  treatment  m  other  European  Spas,  notably  in  Franzensbad.  which 
lies  in  the  northwesterly  comer  of  Austria,  where  it  touches  Saxony 
and  Bavaria. 

Situated  on  a  broad  and  well-cultivated  plain,  through  which 
the  beautiful  river  Eger  and  its  tributaries  flow,  and  at  an  elevation 
of  more  than  1,500  feet  above  the  sea,  it  is  w^alled  about  by  moun- 
tains and  forests  that  protect  it  from  the  cold  winds  and  storms, 
while  the  air  is  necessarily  cool,  pure  and  light,  even  in  the  middle 
of  summer. 

The  town  itself  is  attractive,  quiet  and  restful.  Shady  walks 
are  numerous.     Picturesque  drives  extend  in  every  direction.    Good 


Appendix  291 

hotels  and  apartments  are  numerous.  Excellent  music  and  a  good 
theatre  are  other  attractions.  All  the  bath  houses  and  springs  are 
under  the  control  of  the  municipality,  whose  officers  are  intelligent, 
progressive  and  efficient, 

Franzensbad,  like  Carlsbad  and  Marienbad,  occupies  a  central 
position  in  Europe,  and  is  conveniently  reached  by  the  best  express, 
sleeping  car,  and  de  Luxe  services  from  Dover,  Paris,  Berlin,  Frank- 
fort and  Vienna. 

The  springs  are  a  dozen  in  number,  all  charged  with  carbonic 
acid  gas  and  other  chemical  ingredients,  in  which  they  onl\'  differ 
as  to  relative  proportions. 

According  to  published  analyses,  some  of  them  are  more  strongly 
charged  with  carbonic  acid  gas  than  any  other  springs  in  Europe. 
The  most  prominent  ingredients  are  the  carbonate  of  iron,  Glauber's 
salt,  common  salt,  and  the  alkaline  carbonates,  together  with  the  free 
carbonic  acid.  The  waters  contain  but  small  percentage  of  the  salts 
of  lime,  silicic  acid  and  earthy  matters.  The  springs  in  which  iron 
predominates  are  used  internally  for  improving  the  character  of 
the  blood.  Those  that  contain  alkalies  and  Glauber's  salt  constitute 
a  feature  of  the  treatment.  Those  having  the  largest  amounts  of 
carbonic  acid  and  iron  are  used  for  the  baths. 

The  temperature  of  the  waters  varies  from  50  to  55°  F.  Those 
used  for  bathing  purposes  are  heated  by  different  methods.  By 
the  Pfrieuis  system,  steam  is  turned  into  the  tub,  so  as  to  bring  the 
water  up  to  the  desired  temperature.  The  water  is  by  this  system 
heated  directly.  This,  in  common  parlance,  is  called  the  Mineral 
bath.  The  proportions  of  gas  and  iron  are  small.  It  is  suited  for 
weak,  delicate  or  nervous  persons.  It  is  the  initial  bath  for  those 
who  take  the  cure.  Stronger  baths  are  prepared  by  the  Schzt'ars 
or  Reiner^  systems,  in  which  the  tub  has  a  double  bottom,  the  inter- 
mediate space  being  fitted  with  steam  coils,  so  that  the  water  may 
be  heated  to  the  desired  temperature  without  being  diluted.  Such 
a  bath  is  called  a  Steel  bath,  also  an  arbitrary  word,  but  meaning  that 
the  water  is  heated  indirectly.  These  Steel  baths  are  suited  for 
robust  men  or  women,  or  for  patients  who  require  a  stronger  bath 
than  the  Mineral.  Lastly,  there  is  the  Flozving  bath,  where  the 
carbonated  water,  which  has  been  previously  heated  to  the  required 
temperature,  flows  through  the  tub  in  w^hich  the  patient  is  im- 
mersed. These  last  are  taken  at  the  close  of  a  course  in  heart 
diseases. 

The  appliances  at  the  baths  are  such  that  any  degree  of  strength 


292  Appendix 

can  be  obtained,  and   brine,   the  chloride  of  calcium   or  other  in- 
gredients may  be  added  in  any  proportion  that  may  be  necessary. 

Each  of  the  three  kinds  of  baths,  whether  Mineral,  Steel  or 
Flowing,  has  three  grades,  the  strength  of  the  bath  constantly  in- 
creasing with  each  successive  grade.  In  point  of  strength  the  order 
is  as  follows : 

Mineral,     i  Steel,  i 

2  The  weakest.  2  The  medium. 

3  3 
Flowing,  A 

B   The  strongest. 

C 

In  the  regular  heart  disease  course,  the  patient  takes  his  carbonic 
acid  gas  treatment  in  these  nine  different  grades  of  strength.  The 
weakest  baths  contain  no  brine. 

If  the  duration  of  the  bath  is  not  too  long,  the  effect  is  very 
stimulating,  but  if  too  long,  irritability  and  fatigue  will  be  the 
results.  To  prevent  inhalation  of  the  gas  the  water  should  not  be 
allowed  to  reach  more  than  to  the  middle  of  the  chest,  or  the  tub 
may  be  covered  by  a  linen  sheet.  Inhalation  of  the  gas  will,  of 
course,  cause  some  headache,  dyspnoea  or  palpitation ;  but  as  a 
matter  of  fact  such  an  occurrence  is  very  rare,  because  the  gas 
rises  only  a  few  inches  above  the  level  of  the  water.  At  the  strong 
■flowing  baths,  however,  where  the  agitation  of  the  water  causes  the 
gas  to  rise  higher  than  in  the  other  baths,  there  is  always  an  at- 
tendant in  the  room.  Usually  the  sensations  after  the  bath  are  very 
agreeable ;  the  large  and  airy  bathrooms,  that  are  features  of  the 
Franzensbad  bath-houses,  obviating  the  likelihood  of  any  possibly 
unpleasant  effects  from  inspiring  the  gas.  For  further  particulars, 
the  reader  is  referred  to  the  book  entitled  Franzensbad ;  Its  Mineral 
Waters  and  Baths,  by  Dr.  L.  Felhier,  1904. 

Fellner^  agrees  with  Winternitz  of  Halle  that  the  carbonic  acid 
gas  is  absorbed  by  the  skin,  and  that  it  has  a  reflex  action  on  the 
vaso-motor  centers,  causing  dilatation  of  the  arteries  and  capillaries, 
which  produce  a  sensation  of  warmth.  Through  its  influence  on  the 
pneumo-gastric  it  lessens  the  frequency  of  the  pulse,  and  deepens 
inspiration.    Dilatation  of  the  vessels  permits  them,  of  course,  to  be 


^  Fellner,    Verhand.   der   Clir.   Hcrzkrankheiten,   T904. 


Appendix  293 

better  filled.  Diminution  in  cardiac  frequency  favors  diastole,  so 
that  the  ventricles  are  also  better  filled,  and  discharj^inj:^  more  blood, 
take  up  more  blood  and  so  relieve  venous  congestion.  Deep  breath- 
ing also  increases  the  siphon-action  of  the  heart.  In  these  ways  there 
is  a  tendency  to  restore  the  balance  of  circulation  between  the 
arterial  and  venous  systems.  The  heart  itself  is  likewise  improved, 
for  the  coronary  arteries  are  better  filled,  and  the  organ  is  supplied 
with  more  and  better  nourishment.^ 

According  to  Fellner,  resistance  exercises  also  lessen  the  fre- 
quency of  the  pulse  and  increase  the  blood  pressure,  because  they 
contract  the  muscles,  causing  them  to  press  on  the  delicate  walls  of 
the  veins  and  lymphatics,  facilitating  the  flow  of  their  contents 
towards  the  heart.  The  organ,  therefore,  is  better  filled,  and  the 
left  ventricle  has  more  blood  to  distribute  throughout  the  systemic 
circulation,  and  so  the  tendency  to  congestion  of  the  veins  and  lym- 
phatics, so  common  in  chronic  heart  disease,  is  overcome. 

VII.       REGIMEN    IN    CHRONIC    HEART    DISEASE. 

Rules  to  Be  Observed  by  the  Patient. 

Liquids.  Do  not  drink  more  than  half  a  glass,  to  a  glass  (four 
to  eight  ounces  of  water),  at  meal  time.  Water  may  be  taken  freely 
two  hours  after  eating ;  on  rising  in  the  morning ;  and  at  bed  time. 

In  case  stimulants  are  necessary,  pure  Moselle  wine  can  be  taken 
at  lunch  or  dinner  with  an  equal  quantity  of  water,  preferably  High- 
land water.  Aerated  water  should  be  avoided.  A  small  quantity 
(half  an  ounce)  of  good  whiskey  can  be  taken  in  place  of  the 
Moselle.  Use  no  fermented  liquor,  and  take  alcoholics  only  as  above 
directed.  May  take  Zoolak  or  Vichy.  Avoid  coffee  or  tea,  unless 
the  latter  is  weak.  Take  Postum  in  place  of  cofifee.  Use  milk  only 
if  it  agrees. 

Foods.  Eat  no  white  or  rye  bread.  Use  Graham,  whole  wheat 
bread,  unsweetened  Zwieback  or  toast. 

Fish.  Avoid  salmon  and  white  fish.  Eat  broiled,  baked,  or  boiled 
fish,  but  without  dressings  or  sauces.     May  eat  oysters  and  clams. 

Meats.  May  eat  roast  beef,  mutton,  lamb,  veal,  venison,  sweet- 
bread, fowl  or  game.  Avoid  ducks  and  geese.  Avoid,  however, 
gravies,  stuffed  and  breaded  meats.  May  eat  plain  omelettes  or 
scrambled  eggs. 

Vegetables.     May  eat  peas  and  Lima  beans    (in  moderation), 


'  Many  walks  in  Franzensbad  are  laid  out  with  reference  to  the  Terrain 
cur.  As  the  distances  are  indicated  by  signboards,  patients  can  follow  the 
directions  of  the  physician  in  walking  the  exact  distance  he  prescribes. 


294 


Appendix 


string-  beans,  ovster  i>lant,  tomatoes  ami  spinacli.  koli-rabi.  young 
carrots  and  beets  (stewed),  egg  plant,  rice  and  hominy. 

Dessert.  May  eat  plain  rice  and  hominy,  or  custard,  or  apple 
pudding.  Wine  jellies,  if  not  sweetened ;  stewed  fruits.  May  eat, 
occasionally,  ripe  peaches,  pears,  and  grape  fruit.  May  eat  stewed 
cherries,  pears,  peaches,  and  apples.     Avoid  all  forms  of  cheese. 

Tobacco.     Avoid  all  forms  of  tobacco. 

Eat  slowl\   and  at  regular  hours;  masticate  tiioroughly. 

Do  not  partake  of  a  great  variety  of  dishes  at  any  one  time,  nor 
eat  large  quantities  of  anything  very  hot  or  cold. 

Under-cooked  vegetables,  overdone  meats,  hard-boiled  eggs,  are 
to  be  avoided. 

A  moderate  quantity  of  food  for  adults  should  average  daily 
about  ten  ounces  of  animal  food,  thirty  ounces  of  vegetable  food,  and 
riftv  to  eight\'  ounces  i>f  li(|ui(ls,  princi]nilly  water. 


VII. 


Ill-:     .M(M)ll-IIil)    RIVA     ROCCI     .Sl'lIVGMOMAXOMETliR. 


Fig.  41- 


This  instrument  is  thus  described  by  the  makers:  It  is  an  ap- 
paratus for  estimating  artificial  blood  pressure  or  pulse  force,  modi- 
fied by  Dr.  Henry  W'ireman  Cook,  of  the  Jolms  ll()])kins  Hospital, 
Baltimore,  Md. 

The  most  valuable  indication  derived  from  palpation  of  the  pulse 


Appendix  295 

is  the  indication  of  arterial  tension.  The  value  of  sucli  estimates 
is  in  (Hrect  proportion  to  their  accuracy. 

A  knowle(Ij:^e  of  actual,  definitely  determined  pulse  tension  is  of 
special  value  in  the  diagnosis  of  many  morbid  conditions  where 
variations  from  the  normal  are  characteristic,  as,  for  example,  in 
apoplexy,  traumatic  brain  compression,  surgical  or  traumatic  shock, 
nephritis,  cardiac  diseases,  aneurism,  lead  poisoning,  haemorrhages, 
uraemia,  etc. ;  also  in  the  treatment  of  conditions  where  correction 
of  an  existing  pulse  tension  is  aimed  at,  under  which  are  included 
all  the  conditions  just  mentioned  above,  and  in  addition,  the  larger 
class  of  toxic  cases  in  which  depression  of  the  vaso  motor  system  is 
a  prominent  feature  and  calls  for  stimulation.  In  these  cases  it  is 
specially  important  to  be  able  to  follow  variations  in  pulse-force  ac- 
curately, and  to  meet  such  variations  with  proper  therapeutic 
measures. 

The  apparatus  consists  of  a  system  of  closed  tubes  connected 
with  a  rubber  bulb  held  by  the  operator,  a  hollow  rubber  band 
(placed  around  the  arm  or  leg  of  the  patient) ,  and  a  mercury  mano- 
meter. By  the  law  of  the  diffusion  of  gases,  equal  pressure  is  trans- 
mitted to  every  point  throughout  this  closed  air  system.  When  the 
pressure  is  raised  by  the  operator  to  such  a  point  that  the  pulse  of 
the  patient  distal  to  the  constricting  band  is  obliterated,  the  height 
of  the  mercury  column  in  the  manometer  is  held  to  be  equivalent 
to  the  maximum  arterial  blood  pressure. 

The  arm-piece  is  placed  around  the  patient's  upper  arm,  midway 
between  the  elbow  and  shoulder,  and  adjusted  to  fit.  The  operator, 
with  one  hand,  increases  the  pressure  by  squeezing  the  hand  bulb, 
and.  with  the  other  hand,  palpates  the  patient's  radial  at  the  waist. 
When  the  pressure  just  obliterates  the  pulse  at  the  wrist,  the  height 
of  the  mercury  column  is  noted,  and  it  is  then  allowed  to  drop  slowly 
until  the  pulse  returns.  This  manoeuvre  is  repeated  without  letting 
the  air  out,  and  by  merely  squeezing  and  releasing  the  reservoir 
bulb.  The  point  above  which  the  pulse  is  obliterated  and  below 
which  it  returns  is  the  reading  of  maximum  arterial  blood  pressure. 
A  determination  within  two  or  three  millimeters  should  be  con- 
sidered satisfactory. 

A  reading  of  mean  arterial  blood  pressure  may  be  made  with 
this  instrument,  as  described  by  Prof.  Gumprecht,  by  finding  the 
point  when  the  greatest  excursion  of  the  mercury  column  occurs 
during  cardiac  systole  after  clamping  off  the  tube  leading  to  the 
reservoir  bulb. 


296  Appendix 

The  normal  maxinuini  blood  pressure  averages,  when  lying  at 
rest: 

For  children  of  1  to  3  years 85  to     95  mm. 

For  children  over  3  years 95  to  no  mm. 

F""or  adult  females    115  to  125  mm. 

For  adtilt  males   125  to  135  mm. 

The  mean  arterial  pressure  is  about  three-quarters  of  the  maxi- 
mum. Any  one  at  all  trained  in  pulse  palpation  can  make  an  ac- 
curate reading  at  the  first  trial.  An  estimation  takes  from  fifteen  to 
thirty  seconds. 

Sold  by  the  Kny-Scheerer  Co.,  225  to  233  Fourth  Ave.,  New 
York  City,  or  Eimer  &  Amend,  i8th  St.  and  3rd  Ave.,  New  York 
Citv. 


INDEX. 


Abscess  of  heart,   in. 

Abnormal  rhythm,  171. 

Accentuation  of  heart   sounds,   19. 

Aconite  in   heart  disease,  224. 

Adams-Stokes   syndrome,   278,    186,    187. 

Adherent  pericardium,  168. 

Adonis  vernalis,  227. 

Afifections  of  the  substance  of  the  heart,  102. 

Allorrhythmia,    171. 

Anaemia,  25 ;  murmurs  in,  25. 

Anaemic   necrosis,    in. 

Aneurisms,  251;  abdominal,  258;  aortic,  254;  Bellingham's  treatment,  261; 
cardiac,  288 ;  course,  252 ;  defined  by  radiography,  252 ;  diagnosis,  252 ; 
etiology,  251;  expansile  pulsation,  258;  eye  symptoms,  253;  fusiform, 
251;  miliary,  282;  percussion,  254;  pressure  signs,  253;  of  pulmonary, 
260;  sacculated,  251;  sex  in,  251;  symptoms,  261;  thoracic,  254; 
thrill,  259;  tracheal  tugging  in,  254;  treatment  by  diet,  261;  rest,  261; 
sedatives,  261 ;  Tufnell's  plan,  261. 

Angina  Pectoris,  38,  207;  diagnosis,  213;  etiology,  212;  false,  208;  history,  207; 
in  chronic  aortitis,  272 ;  mild,  208 ;  morbid  anatomy,  212 ;  motoria,  208 ; 
pathology,  219;  primary,  208;  prognosis,  216;  pseudo,  208;  reflex,  212; 
secondary,  2o8j  sex,  214;  severe,  208;  sine  dolore,  213;  symptoms,  213; 
treatment,  214;  true,  208.  • 

Angiomas  of  the  heart,  288. 

Angio-sclerosis,  273. 

Aorta,   atheroma   of   the,   269. 

Aortic   area,  23. 

Aortic  diseases,  67. 

Aortic  insufficiency,  67;  angina  in,  70;  arteriosclerosis  in,  68;  cannon  ball  pulse, 
71;  Corrigan's,  71;  diagnosis,  71;  etiology,  68;  murmurs  in,  70;  or- 
ganic form,  67;  pistol-shot  pulse,  71;  relative  form,  67;  stages,  72;  sud- 
den death  in,  246;  symptoms,  70;  thrill,  70;  triphammer  pulse,  71 ;  venous 
pulse,  71;  water-hammer  pulse,  71. 

Aortic  obstruction,  yj ;  and  aortic  insufficiency  combined,  yj;  diagnosis,  80; 
etiology,  79;  frequency,  yy  \  physiology,  79;  prognosis,  81;  sex,  80; 
symptoms,  80;   without   insufficiency,   78. 

y'U/rtitis,  263 ;  acute  and  chronic,  263,  277 ;  acute  primary,  263 ;  acute  secondary, 
263;  causes  and  modes  of  development,  264;  diagnosis,  267;  etiol- 
ogy,   264. 

Aortitis,  chronic,  267;  causes  and  modes  of  development,  268;  morbid  anat- 
omy, 268;   symptoms,  268;   treatment,  272. 

Aperients,    225. 

Apex  beat,  14. 

Apocynum,    228. 

Apoplectiform  seizures,  282. 

Araiocardia,    181. 

Argentum  Crede,  221. 

Arrhythmia,  173;  causes,  173;  reflex,  173;  toxic,  173. 

Arsenic  in  heart  diseases,  223. 

Arterial   tension,  294. 

Arteriosclerosis,  273 ;  a  senile  change,  275 ;  association  of  with  other  morbid 
processes,  274;  asthma  associated  with,  283;  cardio-vascular  type,  278; 
cardiac  hypertrophy,  276;  cerebral  type,  282. 


2gS  Index 

Arteriosclerosis,  274;  clinical  types  of,  2yS;  embolism  in.  275;  oiulartcritis  in, 
274,  276;  gastro-intestinal  types,  279;  gouty,  2~ji,;  granular  kidney 
in.  2S2;  hypertrophy  of  the  heart  associated  with,  27b;  kidney  disease 
associated  with,  2S1  ;  lead  poisoning  in,  281  ;  mechanical  means  of  de- 
termining arterial  resistance,  293;  mental  overstrain  in  tlie  causation 
of,  284;  of  coronary  vessels,  216,  219;  pathology,  276;  physical  diagno- 
sis, 277;  pulmonary  type,  283;  spinal  type,  283;  syphilitic,  283;  stages  of, 
274;    treatment    of,    284. 

Arteries,  calcareous  infiltration  of,  274. 

Arttrio-capillary    fibrosis.    281.    ^2. 

Arteritis,  277;  acute,  275;  in  infective  diseases,  277;  obliterating,  276. 

Artery,  pulmonary,  82;  anomalies  of  the.  287;  diseases  of  the,  260.  (See 
Pulmonary  arterj'.) 

A'-tificial   bath,   238. 

Asthma,  arteriosclerosis  associated  with,  283;  dolorificum,  207  (see  Angina 
pectoris)  ;   treatment  of,  214. 

Atrophy  of  the  heart,  104,  109. 

Atiieroma,  274. 

Auricle,  left,  41,  58;  dilatation.  41,  58;  hypertrophy,  41,  58. 

Auricle,  right,  41,  58;   dilatation,  41,  58;   hypertrophy,  41,  58. 

Auscultation   in  heart  diseases,  37. 

Author's   tables,   ^,2.    t,Ti. 

Bacteria  in  endocarditis,  28,  46. 
Banting   system,    116. 

Basedow's  disease    (see  Exophthalmic  goitre),   194. 
Batht..  carlxinated,  290;  how  to  prepare  them,  290;  and  e.xcrci>es.  230. 
Baths  in  heart  disease,  290. 
Belladonna,  224. 
Bradycardia,    181. 

Breast-pang    (see  Angina  pectoris),  207. 
Bromide    of    Zinc,    224. 
Brown  atrophy  of  the  heart,  no. 
Brown    induration    of   lungs,   41. 
Brucine,    22;^. 

Bruit;  pistol-shot,  71;  du  diable,  25;  du  scie,  36;  du  rape,  36;  d'oboe.  36;  de 
soiifHc.  36;  diastolic,  55;  auricular  systolic,  55. 

Cactus  grandiflorus,  223. 

Caffeine,    227. 

Calomel,  225. 

Camphor,   224. 

Capillary    pulsation,    71. 

Carbonic  acid  gas  treatment,  the  dry,  230;  the  wet,  230. 

Carcinoma  of  the  heart,  288. 

Carditis.    103. 

Cardiospasm,    219. 

Cardiogram,  14,  15. 

Caton's   method,   220. 

Cereus  grandiflorus,  223. 

Chambers'  method,   116. 

Cheyne-Stokes  respiration,  11,   131,  249. 

Chorea  and  valvular  diseases,  28. 

Clinical  examination  of  the  heart,  7. 

Climate,  223. 

Colloidal  silver,  221. 

Compensation,  40,  41,  53,  222,  249. 

Congenital   affections   of  the   heart,   287. 

Convallaria,   227. 

Cor  bilocular,  287. 

Cor  bovinum,    106. 


Index  299 

Cor  trilocular,  287. 

Cor  villosum,   160. 

Coronary  arteries,  208,  209;  angina  pectoris  in  diseases  of,  208,  209,  210,  212; 
atheroma  of  the,  209;  associated  with  arteriosclerosis,  209;  without  an- 
gina  pectoris,   210. 

Corpulence,    112. 

Corrigan"s  disease,  67,   71. 

Cretsegus,  23. 

Cyanosis,  95;  congenital  heart  lesions  causing,  228;  in  pulmonary  stenosis,  89; 
in  valvular  heart  disease,  35,  89. 

Cysticercus  of  the  heart,  289. 

Cysts  of  the  heart,  288. 

Death,  sudden,  39.  41,  141,  245,  246,  249;  from  bursting  of  aortic  aneurism, 
256,  257,  258;  other  causes,  254,  255,  260. 

Debilitas  cordis  (see  Weak  heart),  103. 

Degeneration,   fatty,  of  the  heart,   124;   hyperdilatation   in,   126. 

Delimitation  of  the  heart,  15. 

Delirium  cordis,   11,   199. 

Dermatographic  pencil,   13. 

Diagnosis  of  heart  diseases,  7. 

Diastolic  sounds,   18. 

Diastolic  murmurs,  249. 

Diet  in  heart  diseases,  225,  292. 

Digestion,    12. 

Digestive  troubles  in  valvular  disease,  25  ;  treatment,,  225. 

Digitalis,  226;  in  arteriosclerosis,  284;  in  valvular  disease,  228;  in  the  treat- 
ment of  cardiac  disease,  229;  substitutes  for,  227. 

Dilatation  of  the  aorta,  272. 

Displacements  of  heart,  16,  142;  in  pleurisy,  1/^4;  in  other  conditions,  145; 
intrinsic,  142;  extrinsic,  142;  prognosis,  142,  144,  158. 

Division  of  cardiac  sounds,  21. 

Diuretics,   28. 

Dropsy;  from  fatty  heart,  131;  in  heart  disease,  40;  treatment  of,  228;  the 
use  of  needles,  228. 

Dulness  in  percussing  outlines  of  heart,  16. 

Durosies's   sign,    72. 

Dwarf  beats,   174. 

Ebstein's    reduction    method,    117. 

Echinococcus  of  the  heart,  288. 

Effusions  into  pericardium,  162. 

Embolism,  39;  of  brain,  39;  of  lungs,  39;  of  liver,  39;  of  spleen,  etc.,  39. 

Endarteritis,  274. 

Endocardiopathies,  27;  age,  28;  angina  in,  38;  auscultation  in,  2>7  \  classifi- 
cation, 27;  compensation  in,  40,  41;  cyanosis  in,  35;  diagnosis,  39;  etiol- 
ogy, 27 ;  embolism  and  apoplexy  in,  39 ;  micro-organisms  in,  28 ;  organic 
and  inorganic  murmurs,  35;  percussion  in,  38;  pathologj-,  28;  pulse,  36; 
rhythm,  36;  statistics,  31;  S3aTiptoms,  28. 

Endocarditis,  acute,  42 ;  benign,  42 ;  blood  examination  in  the  diagnosis  of. 
43 ;  diagnosis,  43 ;  diphtheritic,  43 ;  etiology,  42 ;  prognosis,  43 ;  gonor- 
rheal, 46;  infective.  45;  in  the  exanthems,  42;  malignant,  45;  etiology, 
46 ;  mycotic,  45  ;  septic  or  ulcerative,  45 ;  treatment,  44. 

Epigastric  pulsation,  63,  95,  97,  200. 

Epistaxis,  269,  275. 

Erlinger  system,  242. 

Examination   blank,   8. 

Exercises  in  heart  disease,  229;  passive,  232;  resistance,  22,2;  rationale  of,  292; 
modus  operandi,  238. 

Exocardial   sounds,   26. 


300  Index 

Exophthalmic  goitre,  194  (see  Graves'  disease);  acute,  194;  course  of,  202; 
chronic,  194;  definition,  194;  diagnosis,  194,  200;  essentials,  194;  eti- 
ology, 197;  history,  195;  neurotic  disturbance  in,  197;  palpita- 
tion, 197;  pathology,  197;  pigmentation  in,  199;  primarj-,  194;  sec- 
ondary, 194;  treatment,  203;  tremor,  196. 

Express    wax    crayon,    13. 

Fades  artcrio-sclerotica,  278. 

Fatty  degeneration  of  the  heart,  124;  diagnosis,  129;  etiology,  128;  pathology, 

125;  prognosis,  134;  stages.  125;  treatment,  133. 
Fat  heart,  the,  112;  diagnosis,  114,  133;  prognosis,  123;  treatment,  115. 
Fibroma  of  the  heart,  288. 
Fingers,  clubbing  of,  288. 

Flatness  in  its   relation  to  the  percussion  area,    13. 
Flint    murmur,    66. 
Fluorography,    12. 
Fluoroscopy  in  heart  disease,  12. 
Foramen  ovale,  defective  closure  of,  287. 
Formes  frustes  in  Graves'  disease,   195. 
Fowler's   solution,    115. 
Fragmentation  of  the  heart  muscle,  126. 
Fret)tisse»ieut  cataire.  36. 
Frequent  pulse,  173;  chronic.  179;  etiology,  173;  paroxysmal,  175;  permanent 

'^7S'-  physiology,  174;  prognosis,  177;  temporary.  184;  treatment.  176. 
Franzensbad,  treatment  of  heart  diseases  in,  289. 
Friction   sounds   in   pericardium,   161. 
Fucus  vesculosus.  115. 
Functional  cardiac  diseases.   170. 
Functional  murmurs,  21. 

Gallop-rhythm.   20. 

Gelatiniform  plaques,  266. 

Gout,  arteriosclerosis  in,  273. 

Graefe's  symptoms  in  exophthalmic  goitre,  200. 

Graves'  disease,   194;  treatment  by  galvanic  puncture,  285. 

Gummas  of  the  heart,  288. 

Hairy   heart,    160. 

Head  symptoms  in  heart  disease,  11. 

Haemic  murmurs,  25. 

Haemopericardium,   166. 

Heart,  affections  of  the  heart  substance,  10;  aneurism  of  the,  288;  anomalies 
in  the  chambers  of  the,  287;  atrophy  of  the,  no;  anomalies  in  the  valves 
of  the,  287;  bilocular,  287;  bovine,  106;  carcinoma  of  the,  288;  contour 
of.  13;  condition  of,  in  exophthalmic  goitre.  209;  congenital  anomalies, 
287;  displacements  of  the,  142;  death  from  rupture,  105,  106;  fatty  de- 
generation of  the,  124;  fibroma  of  the,  288;  functional  disorders  of  the, 
170;  gummas  of  the,  136;  head  symptoms  in  disease.  11;  hairy.  167; 
physiological  action  of  the,  18;  hypertrophy  of  the.  104;  infrequent  pulse 
in  aflfections  of  the,  181;  long,  41;  trilocular,  288;  hypertro- 
phy of;  associated  with  the  granular  kidney.  106;  concentric,  ic^;  ec- 
centric. 108;  from  muscular  effort,  104;  from  pericarditis,  168;  from 
plethora,  105;  in  aortic  diseases,  70;  in  mitral  stenosis.  58;  in  preg- 
nancy, 105;  in  pulmonary  stenosis,  90;  irritable,  105;  location  of  the, 
14;  murmurs  of  the,  21  ;  myxoma  of  the,  288;  neurotic,  171  ;  palpitation 
of  the,  170;  parasites  of  the,  289;  percussion  of  the,  234;  rapid  action 
of  the,  173;  sarcoma  of  the.  288:  Schott  system,  230;  sounds  of 
the,  21 ;  sounds,  division  of,  21 ;  strain,  105 ;  suture,  285 ;  syphilis  of  the, 
136;   trilocular,  288. 

Heart,  normal  weight  of,  104. 


Index  301 

Hodgson's  disease,  269. 

Hydatids  of  the  heart,  289. 

Hydrogogues,    222. 

Hydropericardiiim,    163. 

Hyperhydrosis  in  exophthalmic  goitre,  200. 

Hypertrophy  of  the  heart,  104;  concentric,  108;  eccentric,  108;  etiology,   104; 

physiological,  105;  pathological,  105;  stages,  108;  symptoms,  107. 
Hypoplasia  Cordis,   no,   288. 
Hysteria  complicating  exophthalmic  goitre,  200. 

Impulse,    II. 

Infective   endocarditis,  42. 

Infrequent  pulse,  181;  causation,  185;  chronic,  184;  diagnosis,  182;  etiology, 
184;  following  injuries  of  cervical  vertebrae,  184;  paroxysmal  and 
chronic  forms,  184;  pathological,  183;  physiological,  183;  prognosis,  187; 
symptoms,  187;  temporary,   175;  treatment,  176. 

InsuMcientia    myocardii,  103. 

Insufficiency  of  aortic,  70;  mitral,  50;  pulmonary,  82;  tricuspid,  92. 

Iodides,  employment  of,  in  arterial  and  heart  diseases,  225. 

Irritable  heart,  105. 

Jugular  veins,  94;  distention  of,  94;  fulness  of,  94;  pulsation  of,  94. 

Lateral   curvature,   displacements   of  the   heart   in,    145. 
Laxatives,  225. 
Leiter's  tubes,  261. 
Lipomas  of  heart,  288. 

Liver,  examination  of,  12;  cirrhosis  of  in  valvular  disease,  24;  hob-nail,  24. 
Lungs,  examination  of,  12;  embolism  of  in  heart  disease,  39;  in  aortic  disease, 
•80;  mitral  obstruction,  63;  oedema  of  the,  95. 

Management  of  heart  diseases,  220. 

Massage,  238;  general,  239;  abdominal,  239. 

Measurement  chart,  9. 

Micro-organisms  in  heart  disease,  28. 

Milk-spots  of  the  pericardium,  160. 

Misplaced  heart,    in. 

Missed    beat,    11. 

Mitral  area,  24. 

Mitral  insufficiency,  regurgitation  or  incompetence,  50;  and  mitral  obstruction 
combined,  53;  compensation  in,  52;  diagnosis,  54;  etiology,  51 ;  inorganic 
or  relative,  53;  organic,  51;  physiology,  57;  prognosis,  247;  symptoms, 
51;  statistics,  31;  temporary,  51;  venous  pulsation  in,  52. 

Mitral  murmurs  in  anaemia,  26. 

Mitral  obstruction  (stenosis),  55;  age,  60;  diagnosis,  57;  diastolic  murmur 
61;  embolism,  63;  Flint  murmur,  66;  physiology,  58;  physical  signs,  60 
presystolic  murmur,  61;  prognosis,  60;  pulse,  60;  stages,  59;  sex,  60 
statistics,  56;  symptoms,  66;  thrill,  66. 

Morbus  coeruleus,  288.     (See  Congenital  affections  of  the  heart.) 

Motility  of  the  heart.   16. 

Murmurs,  22;  accidental,  21;  anaemic,  26;  musical,  35;  valvular,  21. 

Myasthenia  cordis,  103. 

Myocardial  affections,   102. 

Myocarditis,    103. 

Myomalacia  cordis,  in. 

Myoma  s,  288. 

Myxomas  of  the  heart,  288. 

Nauheim  methods,  230 ;  Franzensbad  methods,  289 ;  the  artificial  bath,  238. 
Needles  in  dropsy,  228. 

Nervous_  system,  symptoms  referable  to  the,  207 ;  in  exophthalmic  goitre,  197. 
Neuralgia  cordis,  207  (see  Angina  pectoris). 


j02  Index 

Neuralgia  (^Ic.vtis  cariiiaci,  207  (see  Angina  pectoris). 

Neuroses  of  the  heart,  170. 

Neurotic   heart.    170. 

New  growths   in  heart,  288. 

Nitrites,   224. 

Nitroglycerine,  224. 

Obesity,  112;  etiology,  112;  symptoms,  112;  treatment,  112. 
Oertel's   plan,    117. 
(.)ligocardia.    181. 
Opiates,  222. 
Organic  murmurs,  21. 

Pain  in  heart  disease,   11. 

Pain,  cardiac  pathology  of,  11;  in  angina  pectoris,  213;  in  aortic  aneurism, 
-54- 

Palpitation,  11,  171;  causes,  170;  direct,  170;  prognosis,  171;  reflex.  170;  symp- 
toms,  171;  toxic,   170;  treatment,   172. 

Pancarditis.    103. 

Paracentesis   of  the   pericardium.    165. 

Paraldehyde,  225. 

Parasites  of  the  heart.  289. 

Percussion,    38,    234. 

Pericardial  diseases,  159. 

Pericarditis,  159;  acute,  160;  chronic,  168;  course,  162;  diagnosis,  160;  eti- 
ology, 159;  morbid  anatomy,  160;  physical  signs,  161;  primary,  159; 
prognosis,  163;  secondary,  159;  symptoms,  161;  treatment,  162;  tuber- 
cular,  167. 

Pericardium,  adherent,  168;  air  in  the,  168;  blood  in  the,  166;  dropsy  of  the, 
166;  effusion  of  serum,  162;  paracentesis  of  the.  165;  pus  in  the,  167. 

Physical  examination  of  the  heart,  13. 

Physiology'  of  heart's  action,   18. 

Pilocarpine,  227. 

Pleural   friction   sounds,   26. 

Pneumopericardium.    168. 

Position  of  heart,   13. 

Praecordium.   bulging  of.    163. 

Pregnancy,  cardiac  hypertrophy  in,  105;  chronic  valvular  disease  in,  243; 
prognosis,  243. 

Premature  beats,  174. 

Presystolic    murmurs,   66. 

Presystolic  sounds,  18;  bruit.  55. 

Prognosis  in  heart  diseases,  244;  age,  244;  embolism,  245;  in  functional  dis 
cases.  244;  in  valvular  lesions,  245;  myocardial,  244;  order  of  gravity, 
248;  relation  to  compensation,  249;  sex,  244. 

Pulmonary,  aneurisms  of  the,  260;  area,  23;  congenital  anomalies  of  the 
288;  obstruction  or  stenosis  of  the,  87;  associated  with  congenital  anom- 
alies, 85;  diagnosis,  89;  etiology,  85,  89;  insufficiency  of  the,  82;  hjemor- 
rhage,  41;  physical  signs,  90;  prognosis,  86,  90;  symptoms,  85;  treat- 
ment, 86,  91. 

Pulse,  7;  arrythmic.  11;  alternating.  11;  arteriosclerotic,  7;  bigeminal,  11;  can- 
non-ball, 71;  capillary.  71;  Corrigan's,  71;  deficient,  11;  frequent,  lO; 
infrequent,  7,  10;  intermittent,  11;  large,  7;  paradoxical,  173;  premature, 
174;  quick,  7;  small,  7;  trigeminal,  11. 

Pupils,  inequality  of  the  in  aneurism  of  the  transverse  portion  of  the  aorta, 

Pyopericardium.    167. 
Ramollisscment  du  Cccur,  124. 
Reduplication   of  sounds,  20. 
Regimen  in  chronic  heart  disease,  292. 


Index 


303 


Residence,  choice  of,  223. 
Respiration,   Cheyne-Slokcs,    II,   249. 
Respiration  in  heart  disease,  11. 
Retraction  of  apex,  169. 
Rheumatism,  relation  of  to  endocarditis,  28. 
Rotter's   operation,  286. 

Rhythm,  8;  cardiac,  12,  19;  double,  20;  embryocardial,  20;  foetal,  20;  gallop, 
II,  20;  pulse,  12;  triple,  11,  20. 

Sarcoma  of  the   heart,  288. 

Schott  system  of  exercise,  230. 

Sclerosis,  arterial    (see   Arteriosclerosis),   273. 

Segmentation  of  heart  muscle,  126. 

Septic   diseases,  endocarditis   in,  46. 

Septum,  cardiac  defective  development  of,  288. 

Sex,  as  affecting  prognosis,  243. 

Skiagraphy,  12;  Skin  changes  in  the,  in  exophthalmic  goitre,  199. 

Sodium,   sulpho-carbolate   of,   221. 

Sounds,  cardiac,  21. 

Spanocai'dia,    181. 

Sparteine,  227. 

Sperling's  tables,  31. 

Sphygmomanometer,  231,  293. 

Sphygmograph,  2,7,   175. 

Spleen,  examination  of,  12 ;  embolism  of  in  endocarditis,  48. 

Stellwag's  sign  in  exophthalmic  goitre,  201. 

Stenocardia   (see  Angina  pectoris),  207. 

Stenosis,  aortic,  77;  mitral,  55;  pulmonary,  86;  tricuspid,  98. 

Sternalgia    (see   Angina   pectoris),   207. 

Streptococcus  sera,  221. 

Strophanthus,  227 ;  as  a  substitute  for  digitalis,  227. 

Strychnine  in  heart  diseases,  223. 

Sudden  death,  39,  in,  114,  246,  249. 

Sulpho-carbolates  in  infective  diseases,  221. 

Supra-renal  extract,  223. 

Surgery  of  the  heart,  285. 

Suture  of  the  heart,  285. 

Sweating,  excessive,  in  exophthalmic  goitre,  200. 

Syncope   dolorosa,  207. 

Sympathetic  system,  changes  in,  in  exophthalmic  goitre,  197,  205. 

Symptom,  v.  Graefe's,  in  exophthalmic  goitre,  200. 

Syphilis  of  the  heart,  136;  angina  in,  139;  aortitis  in,  139;  diagnosis,  139;  endo- 
carditis in,  139;  frequency,  140;  frequent  pulse  in,  139;  in  aneurism  of 
the  aorta,   139;   pathology,   137;   treatment,   141;   prognosis,   141. 

Systolic  sounds,  18. 

Tachycardia,  174. 

Temperature   in  heart  disease,   11. 

Terrain  cur,  230. 

Thrill,  12,  161  ;  purring,  2^,  63. 

Thrombosis   of  veins,  40,    131. 

Thyroid  extract,    118. 

Tobacco  heart,   171. 

Tracheal  tugging,  a  sign  of  aneurism  of  the  transverse  portion,  254. 

Treatment  of  heart  disease,  220. 

Tremor  in  exop-hthalmic  goitre,   196. 

Trional,  225. 

Tricuspid  area,   24. 

Tricuspid   insufficiency,   92;   acquired.   92;    congenital,   92;    diagnosis.   93,   96; 

frequency,  92;  morbid  anatomy,  93;  murmurs.  96;  organic  lesions,  93; 

inorganic,  93;  physiology,  93;  prognosis,  97;  relative,  93;  statistics,  92; 

symptoms.  95 ;  venous  pulsation  in.  94. 


304  Index 

Tricuspid  obstruction  (stenosis),  99;  age,  99;  and  mitral  obstruction,  100; 
congenital  form,  99;  diagnosis,  100;  prognosis,  lOi ;  sex  in,  99;  symp- 
toms.  100. 

Trousseau's  plan,   116. 

Tuberculosis  of  the  heart,  104;  stenosis  of  the  pulmonary  valve  associated 
with,  90. 

Tugging,  tracheal,  a  sign  of  aneurism  of  the  transverse  portion  of  the  arch  of 
the  aorta,  254. 

Treatment  of  heart  disease,  220;  in  acute  simple  endocarditis,  220;  in  acute 
infective,  221;  in  angina  pectoris,  214;  in  chronic  valvular  disease,  221; 
in  fatty  degeneration,  132;  in  fat  heart,  115;  in  functional  disorders,  171. 

Tumors  of  tlie  heart,  288;  Nauheim  methods,  230. 

Urine,  examination  of,  24. 

Vaso-dilators,  224. 

Valerian,  224. 

Valves,  relative  position  of,  15,  17. 

Vegetable-fibre  paper,   13. 

Venesection  in  heart  diseases,  222. 

Veins,  distention  of,  94;  pulsation  of  97,  100;  true,  94;  false,  94. 

Venous  hum,  25. 

Venous  murmurs,  25. 

Vibration,   238. 

Von  Graefe  symptom  in  Graves'  disease,  200. 

Weak  heart,   103. 

White  infarct,   in. 

"Withered-apple"  heart,  no. 

Work,  muscular,  cardiac  hypertrophy  from,  104- 

Worry,  arteriosclerosis  from,  284. 


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